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THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 


PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 

MRS.  PRUDENCE  W.  KOFOID 


PATHOLOGICAL 
ANATOMY  OF   THE   EAR. 

BY 

HERMANN   SCHWARTZE,  M.  D., 

PROFESSOR   IN   THE   UMVERSITY    OF   HALLE   a./S. 


WITH  THE  AUTHOR'S  RE  VIS  10 XS  AND  ADDITIONS,  AND 
WITH  THE  ORIGINAL  ILLUSTRATIONS. 


TRANSLATED    BY 

J.  ORNE   GREEN,  A.  M.,  M.  D., 


BOSTON: 

HOUGHTON,  OSGOOD  AND   COMPANY. 

GTbe  Kibcrsitic  Press,  CambriUsc 

1878. 


Copyright,  1878, 
Br  J.  ORNE  GREEN. 

All  rights  reserved. 


RIVERSIDE,   CAMBRIDGE: 
ELECTBOTTPED    AND    PRINTED 
H.  0.  HOOGHION  AND  COMPANY. 


■RFIQB 


TRANSLATOR'S   PREFACE. 


Schwartze's  " Pathological  Anatomy  of  the  Ear" 
constitutes  the  sixth  part  of  Kleb's  "  Handbook  of 
Pathological  Anatomy."  It  is  the  only  comprehen- 
sive work  strictly  devoted  to  the  pathological  anat- 
omy of  this  organ,  and  on  account  of  the  opportu- 
nities and  devotion  of  the  author  in  this  special 
field,  his  well-known  thoroughness  and  strict  impar- 
tiality in  scientific  researches,  it  is  a  most  valuable 
addition  to  the  literature  of  otology.  It  is  essen- 
tially a  hand-book  on  the  subject  of  which  it  treats, 
a  small  amount  of  space  often  sufficing  to  give  the 
results  of  researches,  the  laboriousness  of  which  can 
only  be  appreciated  by  those  who  have  been  engaged 
in  similar  work. 

The  translation  is  issued,  both  to  show  what  has 
already  been  accomplished  in  this  branch  of  otology, 
and  with  the  hope  of  directing  still  further  attention 
to  pathological  anatomy,  the  only  solid  foundation 
for  a  still  further  advance  in  our  knowledge  of  dis- 
eases of  the  ear.     It  has  been  the  object  to  repro- 


iv  TRANSLATOR'S  PREFACE. 

cliice  the  work  in  the  same  concise  language  as  the 
original,  together  with  the  additions  and  corrections 
which  the  author  has  made  since  the  publication  of 
the  German  edition.  The  histology  of  the  ear,  to 
which  reference  is  often  made,  will  be  found  fully 
described  in  Strieker's  "  Manual  of  Histology  "  and 
Koelliker's  "  Hand-book  of  Histology." 

On  account  of  the  large  number  of  references, 
abbreviations  are  freely  used.  The  first  citation  of 
a  work  will  be  found  with  the  full  title ;  in  further 
citations  of  the  same  work,  abbreviations  are  often 
used.  Among  the  most  frequent  of  these  abbrevia- 
tions are  A.  f.  0.,  for  the  Archiv  fur  Ohrenheilkunde, 
M.  f.  0.,  for  the  Monatschrift  fur  Ohrenheilkunde, 
and  A.  f.  A.  und  0.,  for  the  Archives  of  Ophthalmol- 
ogy and  Otology. 


CONTENTS. 


Page 

Literature 1 

ixtroductiox 2 

Method  of  Dissection 5 

The  Temporal  Boxe  in  general 8 

Malformations       .........       8 

Rarefaction 9 

Hyperasmia  .  .  .  .  .  .  .  .  .10 

Atrophy 10 

Osteoporosis  .  .  .  .  .  .  .         .  .11 

Hyperostosis     .  .  .  .  .  .  .  .  .  11 

Caries  and  Necrosis       .         .         .         .         .         .         .         .11 

Fracture 19 

New  Growths        .........     ilO 

Exostoses 20 

Tubercle 21 

Cholesteatoma 21 

Malignant  Tumors  .......     26 

The  Auricle 28 

INIalformations 28 

Othoematoma    .  .  .  .         .         .  .         •  -  35 

Inflammations        .........  36 

New  Growths   .  .  .  .  .         .  .         .  .  37 

The  External  Meatus 38 

]\Ial formations  .........  38 

Hyperemia  and  Hemorrhage         ......  40 

Inflammations  and  their  Results         .          .          .          .         .  41 

Erythema      .  .  .  .         .         .  .  .         .42 

Eczema     .........  42 

Furuncle        .........  43 

Ulceration         .........  46 


VI  CONTENTS. 

Collapse 47 

Hyperostosis         .         .         .         .         .         .         .         ,         .47 

Caries  and  Necrosis .         .         .         .         .         .         .         .  47 

Anomalies  of  Secretion 48 

New  Growths 50 

Concretions   .........  50 

Encysted  Tumor         .         .         »         .         .         .         .  50 

Milium 50 

AVarts 50 

Polypi 50 

Exostoses  .........  51 

Epithelioma  .         .         .         .         .         .         .         .         .52 

Cholesteatoma    .         .         <,         .          .          .          .          .  52 

Enchondroma         ........  53 

Cylindroma        .          .         «         .         .          .          .          .  53 

Injuries 54 

Parasites           .........  54 

The  Drum-membrane 57 

General  Remarks 57 

Malformations      .........  58 

Hyperaemia       .........  61 

Hemorrhage  .  .  .         .         .  .  .  .  .02 

Inflammation  and  its  Residts      ......  63 

(1.)  Anomalies  of  Color  and  Transparency,  Thickening, 

Opacity,  and  Calcification 66 

(2.)   Anomalies  of  Curvature     .          .         .          .          .  67 
(3.)  Perforation  and  Cicatricial  Formation    .          .          .76 

(4.)  Detachment  of  the  Manubrium  ....  82 

(5.)   Abscess 84 

(6.)   Ulceration 84 

(7.)   Anomalies  of  the  Membrana  Flaccida  Shrapneli     .  85 

Atrophy  (hernia  and  emphysema)      .....  85 

New  Growths 86 

Epithelioma        .......  86 

Cholesteatoma 87 

Tubercle 88 

Rupture 89 

Fracture  of  the  Manubrium 90 

The  Tympanum 90 

General  Remarks     ........  90 

Malformations      .........  92 

Hypercemia  and  Hemorrhage    ......  93 


CONTENTS. 


Vll 


Catarrhal  Inflammation 

(1.)   Serous  Catarrh  ...... 

(2.)  Mucous  Catarrh     ...... 

(3.)  Purulent  Catarrh 

Croupous  and  Diphtheritic  Inflammation 

Caseous  Inflammation        ....... 

Adhesive  Inflammation  ...... 

Sclerosis 

Caries  of  the  Tympanum 

Pathological  Changes  of  the  Ossicles  and  their  Articulations 
Pathological  Changes  of  the  Tympanic  Muscles    . 
Injuries    .......... 

Foreign  Bodies 

New  Growths  ......... 

Aural  Polypi  ....... 

Cholesteatoma  ........ 

Exostoses      ........ 

Hyperostoses      ........ 

Cysts     .        ' 

Epithelial  Cancer      ....... 

Osteosarcoma         ....... 

Tubercle  ......... 


95 
96 
97 
100 
103 
104 
105 
111 
113 
114 
122 
123 
123 
124 
124 
128 
128 
129 
129 
129 
129 
130 


The  Eustachian  Tube 

General  Remarks      .... 
Malformations      ..... 
Hyperasmia  and  Hemorrhage    . 
Inflammation        .... 

Ulceration 

Contraction  and  Enlargment 

Adhesions 

New  Growths       .... 

Polypi 

Exostoses      .... 
Foreign  Bodies  .... 

Pathological  Changes  in  the  Tubal  Muscles  . 


130 
130 
132 
132 
133 
135 
137 
139 
141 
141 
141 
141 
142 


The  Mastoid  Process 142 

General  Remarks 142 

Malformations      .........   143 

HyperjEniia  and  Hemorrhage     .         .  .  .  .  .144 

Catarrhal  Inflammation  of  the  Pneumatic  Cells  of  the  Bone  .   144 
Periostitis  Externa  ........        145 

Caries  and  Necrosis 146 


Vlll  CONTENTS. 

Eburnation  (Sclerosis)       .......        149 

P'raeture 149 

New  Growths    .  .  .  .  .  .  .  .  .150 

Polypi 150 

Cholesteatoma  .  .  .         .  .  .  .  .150 

Epithelial  Cancer  .......   150 

The  Ixnkr  Ear  and  Auditory  Nerve        .        .        .        .151 

General  Keniarks 151 

Malformations  .  .         .  .         .  .  .  .  .154 

Antemia       ..........   155 

Hypera^mia       .  .  .  .  .  .  .  .  .156 

Hemorrhage  .  .  .  .  .  .  .  .  .157 

Inflammation  and  its  Results     .  .  .  .  .  .158 

Caries  and  Necrosis      ........   1G2 

New  Growths  .  .  .  .  .  .  .  .         .        1G5 

Injuries         .  .  .  .  .  .  .  .   1G6 

Diseases  of  the  Auditory  Nerve  between  its  Central  Origin 
and  its  entrance  into  the  Labyrinth        .         .         .         .167 


THE 

PATHOLOGICAL  AMTOMY  OF  THE  EAR. 


LITERATURE. 

Duverney,  Traite  de  I'Organe  de  I'Ouie.  Paris,  1683. — Bauliinus, 
Diss,  de  Auditus  Lajsioiie.  Basel,  1687.  —  Valsalra,  De  Aure  Humana. 
Bonn,  1704.  — Rlviniis,  De  Auditus  Yitiis.  Leipzig,  1717.  — Morffaf/ni, 
De  Sedibus  et  Causis  Morborum.  1766.  —  Lieutaud,  Historia  Anatomi- 
co-Med.  1767.  (This  contains  in  the  fourth  book,  under  Auris  LfEsiones, 
five  very  short  clinical  communications  on  the  collection  of  mucus  in  the 
inner  ear  cavities  of  children,  on  the  collection  of  pus  in  the  tympanum, 
on  thickening  of  the  tympanic  lining  membrane,  on  thickening  of  the 
drum-membrane,  and  on  congenital  absence  of  the  incus  in  a  deaf  mute; 
all  collected  from  foreign  authors,  Fabricius  ab  Aquapendente,  Mor- 
gagni,  etc.  Also  in  the  third  book  are  two  cases  of  caries  ossis  petrosi, 
Xos.  108  and  4D6.) 

KoJiIer,  Beschreibung  der  Loderschen  Sammlung.  Leipzig,  1795  (con- 
taining, on  pages  146-160,  only  descriptions  of  normal  preparations). — 
Vuigtel,  Handbuch  der  Pathologischen  Anatomie.  Halle,  1804.  — Saun- 
ders, J.  C,  The  Anatomy  of  the  Human  Ear,  illustrated  by  a  series  of 
engravings  of  the  natural  size ;  with  a  Treatise  on  the  Diseases  of  that 
Organ,  etc.  London,  1806.  Second  edition,  London,  1817.  Third  edi- 
tion, London,  1829.  —  Olio,  Handbuch  der  Pathologischen  Anatomie  des 
Menschen  und  der  Thiere.  Breslau,  1814.  S.  39-41.  S.  180-185.— 
Meckel,  J.  F.  Handbuch  der  Menschlichen  Anatomie.  Halle  and  Berlin, 
1815.  —  i^/ewc/^maHn,  Leichenoffnungen.  Erlangen,  1815.  S.  250.  (Case 
of  osteo-sclerosis  of  the  temporal  bone  in  a  deaf  mute.)  —  Otto,  Seltene 
Beobachtungen  zur  Anatomie,  Physiologic  und  Pathologic  gehorig.  I. 
Heft.  Breslau,  1816.  S.  Ill,  112.  (Describes  the  closure  of  the  Eusta- 
chian tube  by  hardened  mucus  and  the  collection  of  a  thick,  clear,  jelly- 
like mass  in  the  tympanum  and  in  the  labyrinth  as  the  most  common  path- 
ological conditions.     Once  he  found  adhesion  of  the  ostium  pharyngeum 


2  PATHOLOGY  OF    THE  EAR. 

tiibaa,  and  once  he  found  the  tympanutn  filled  with  pseudo-membranes.  — 
lUird,  Traite  des  Maladies  de  1' Oreille.  Paris,  1821.  —  0/?o,  Xeue  sel- 
tene  Beobachtungen  zur  Anatomie,  Physiologic  und  Pathologie  gehorig. 
Berlin,  1824.  S.  4,  9G,  97.  — Beck,  Krankheiten  des  Gehororgans.  Frei- 
burg, 1827.  —  Saissy,  Essai  sur  les  Maladies  de  I'Oreille  interne.  Paris, 
1827. —  WitUjenstein, 'SoxinuW^.  de  Anatomia  Auris  Pathologica.  Diss. 
Inaug.  Berlin,  1831.  —  Cruoeilhier,  Anatomie  Pathologique  du  Corps 
Humain.  2  vols.  Text  and  Atlas.  Paris,  1^32-42.  —  Lincke,  Handbuch 
der  Ohrenheilkunde.  Leipzig,  1837.  Bd.  I.  S.  b'td-&bZ.  —  Hyrll, 
Beitrage  zur  Pathologischen  Anatomie  des  Gehororgans.  Oesterr.  Med. 
Jahrb.  XI.  1838,  and  in  other  places.  —  Ammon,  Angeborene  chirurg. 
Krankheiten  des  Menschen.  Mit  Tafeln.  Berlin,  1840.  — PappenJieim, 
Specielle  Gewebelehre  des  Gehororgans.  1840.  —  Nuhn,  Commentatio 
de  Yitiis,  quaj  Surdo-Mutitati  subesse  solent.  Heidelberg,  1841.  — 
Bochdalek,  Pathologisch-anatomische  Untersuchungen  der  Gelior-  und 
Sprachwerkzeuge  bei  Taubstummen.  OesteiT.  Med.  Jahrb.  1842,  and 
in  other  places.  —  Kuh,  Klinische  Beitrage  zur  Kenntniss  der  Entziin- 

dung  der  inneren    Abtheilungen   des    Gehororgans.     Breslau,  1847 

Guckelherger,  Beitrage  zur  Pathologischen  Anatomie  der  Entziindung  des 
Hcirorgans.  Zeitschr.  fiir  Chir.  und  Geburtsh.  VII.  3.  1854.  —  Rau, 
Lehi'buch  der  Ohrenheilkunde.  Berlin,  185G.  —  Stanley,  £■(/?<?.,  Results 
of  Fifty-six  Dissections  of  the  Ear.  Med. -Chirurg.  Transactions,  vol. 
39.  1856.  —  Toynhee,  Catalogue  of  Museum.  1857. —  Von  Troeltsch, 
Anatomie  des  Ohres.      1860. 

Also  the  text  books  of  otology  by  Wilde  (1853),  Toynbee  (1860), 
Bonnafont  (1860),  Von  Troeltsch  (1st  edition,  1862,  6th  edhion,  1877), 
Moos  (1866),  Gruber  (1870),  etc.;  the  special  journals  for  ear-diseases, 
viz.,  Archiv  fiir  Ohrenheilkunde,  Monatschrift  fiir  Ohrenheilkunde,  An- 
nales  des  Maladies  de  I'Oreille  et  du  Larynx,  Archives  of  Ophthalmol- 
ogy and  Otology;  Virchow's  Archiv  fiir  Pathologische  Anatomie,  Archiv 
fiir  Phys.  Heilkunde  von  Wagner,  Med.  Chirurg.  Transactions,  Guy's 
Hosjiital  Reports  and  articles  distributed  in  innumerable  other  journals. 

Joseph  Toynbee  (f  1866)  is  considered  the  founder 
of  the  pathological  anatomy  of  the  ear.  He  was  the 
first  who,  in  a  thorough  and  systematic  manner,  de- 
termined the  principal  pathological  changes  and  es- 
tablished the  fact  that  the  majority  of  these  changes 
were  situated  in  the  tympanum,  or,  as  it  is  more  com- 
monly expressed,  in  the  middle  ear. 

Toynbee  published  the  results  of  his  numerous  dis- 


INTRODUCTION.  3 

sections  in  the  Medico-Cliirurgical  Transactions  (1841- 
1855),  and  in  the  Transactions  of  the  Pathological 
Society  of  London  (1849-1856).  Somewhat  later 
(1857)  they  were  given  in  an  independent  work  with 
the  title  "  A  Descriptive  Catalogue  of  Preparations 
Illustrative  of  the  Diseases  of  the  Ear  in  the  Musenm 
of  Joseph  Toynbee,"  and  also  in  his  work  "  Diseases 
of  the  Ear,  their  Nature  and  Treatment,"  which  ap- 
peared in  1860'.^ 

All  that  had  been  done  towards  the  anatomical 
foundation  of  aural  pathology  by  the  few  physicians 
and  anatomists  before  Toynbee,  is  but  little  compared 
with  the  mass  of  his  material,  and  although  the  scat- 
tered facts  which  have  been  made  known  by  Val- 
salva, Duverney,  Morgagni,  Itard,  Hyrtl,  and  others, 
are  of  value,  still  i\\Qy  are  separated,  few  in  number, 
and  relate  chiefly  to  such  aural  affections  as  are  asso- 
ciated with  otorrhoea  and  lead  to  direct  flital  results. 

In  the  further  development  of  the  pathological  an- 
atomy of  the  ear,  after  Toynbee,  German  physicians 
have  been  principally  active,  not  the  anatomists,  how- 
ever, but  practicing  physicians  (Von  Troeltsch,  Volto- 
lini,  Lucae,  Politzer,  Gruber,  Magnus,  Zaufal,  Moos, 

1  The  Toynbee  collection  of  pathological  preparations  of  the  ear  con- 
sists of  more  than  eight  hundred  specimens,  mostly  dry,  and  is  now  in 
Hunter's  Museum  of  the  College  of  Surgeons,  London.  In  Germany, 
except  numerous  private  collections  of  individual  teachers,  there  only 
exists,  so  far  as  I  know,  a  single  large  public  collection,  namely,  in  the 
Pathological  Institute  of  Leipzig,  where  it  was  formed  by  the  late  Wendt 
and  placed  under  the  care  of  Prof.  E.  Wagner.  For  the  beginner  the 
inspection  of  such  large  collections  and  of  the  best  preparations  is  not  of 
so  mucli  value  as  personal  dissection.  The  examination  of  ear  prepara- 
tions is  of  the  most  use  for  him  who  made  them;  for  another  observer 
only  of  value  when  a  number  of  preparations  are  placed  together  for 
examination  of  some  particular  point. 


4  PATHOLOGY  OF   THE  EAR. 

Wendt  (t  1875),  Kessel,  and  many  others).  The 
work  of  the  anatomists  is  confined  to  some  isolated 
facts  which  have  been  communicated  incidentally  by 
Yon  Meckel,  Otto,  Bochdalek,  Yirchow,  A.  Bottcher, 
C.  E.  E.  Hoffman,  Klebs,  Heller,  and  others.  Among 
the  non-German  authors,  Bonnafont  and  Hinton 
(t  1875)  should  be  placed  in  the  front  rank.  In  path- 
ological histology  of  the  middle  ear,  Wendt  had  la- 
])ored  with  particularly  good  results  of  late  years, 
but  has  unfortunately  been  called  from  his  work  by 
an  unexpected  early  death.  The  pathological  his- 
tology of  the  labj'rinth  of  the  ear  is  still  in  the  first 
stages  of  its  development,  and  needs  the  services  of 
an  extraordinary  anatomist  who  must  w^ork  deeply 
and  thoroughly  in  this  most  difficult  field  for  years 
to  bring  forth  any  result.  What  has  been  done  by 
some  in  this  field,  of  late  years,  with  the  most  earnest 
endeavors,  is  scarcely  more  than  a  sad  dilettanteism, 
and  has  no   special  value  for  science. 

A  systematic  compilation  and  revision  of  the  path- 
ological anatomy  of  the  ear  has  not  been  attempted 
since  the  work  by  Lincke,  who  confined  himself  al- 
most entirely  to  the  history  of  malformations,  and  on 
this  account  I  must  bee?  indulg-ence  for  anv  incom- 
pleteness  or  defect  in  my  work.  I  desire,  however, 
to  lay  special  stress  on  the  trustworthiness  of  all  the 
facts  which  are  stated,  and  to  the  literary  complete- 
ness of  all  cited  publications.  Where  the  stated  facts 
are  not  derived  from  personal  observation  and  in- 
vestigation, the  result  of  nearly  twenty  years'  ex- 
perience in  the  anatomical  and  practical  study  of 
the  human  ear,  the  name  of  my  authority  is  given 
in  brackets. 


DISSECTWX  OF   THE  EAR.  5 

A  typically  normal  ear  is  comparatively  seldom 
found  in  dissection.  In  most  cases  abnormal  condi- 
tions of  congestion  and  secretion,  especially  in  the 
middle  ear,  are  met  with  which  are  certainly  in  the 
majority  of  cases  to  be  considered  as  phenomena 
brought  on  during  the  agony,  or  else  as  having  oc- 
curred post-mortem.  These  changes  are  quite  regu- 
larly found  in  the  bodies  of  those  persons  who  have 
died  from  heart  and  lung  diseases  and  are  the  result 
of  venous  congestion  in  the  branches  of  the  vena 
cava  superior.  It  is  therefore  necessary  to  avoid  lay- 
ing too  great  a  clinical  value  on  these  insignificant 
pathological  alterations,  especially  if  they  are  found 
on  both  sides. 

The  diseases  which  most  frequently  affect  the  ear 
are  the  acute  exanthemata,  typhus,  acute  and  chronic 
catarrh  of  the  nose  and  naso-pharynx  with  their  re- 
sults, tuberculosis,  diseases  of  the  heart,  syphilis, 
puerperal  fever,  and  chronic  alcoholismus. 

In  dissecting  the  ear  it  is  absolutely  necessary  for 
the  beginner  to  fix  upon  a  regular  method  of  prepa- 
ration in  order  that  important  parts  may  not  be  for- 
gotten, or  destroyed  during  the  dissection. 

The  following  is  the  method  of  dissecting  given  by 
Professor  Lucae :  — 

I.  Removed  of  the  Temporal  Bone  with  the  tvhole  Ear  from  the 
Skull.  A  small  chisel  is  driven  downwards  transversely  through  the 
sella  turcica  between  the  processus  clinoideus  medior  and  anterior, 
and  again  a  second  time  through  the  centre  of  the  eminence  of 
Blumenbach.  Into  the  first  openmg  a  small  Langenbeck's  resec- 
tion-saw is  inserted  perpendicularly,  and  the  bone  is  then  sawn  out- 
wards through  the  body,  and  greater  wing  of  the  sphenoid  to  the 
foramen  rotundum  of  the  sphenoid.  The  direction  is  then  changed 
slightly  backwards  and  outwards,  and  the  cut  continued  through  the 


6  PATHOLOGY  OF  THE  EAR. 

bone,  parallel  with  the  crista  ossis  jje'-.rosi,  to  the  point  where  the 
squamous  portion  of  the  bone  bends  upwards.  The  saw  is  then  to 
be  inserted  in  the  opening  already  made  with  the  chisel  in  the  emi- 
nence of  Blumenbach  and  a  cut  made  outwards  and  backwards,  be- 
hind and  parallel  with  the  crista  ossis  petrosi,  through  the  condyloid 
l^rocess  of  the  occipital  bone  and  for  a  part  of  the  way  in  the  lateral 
sinus,  the  cut  ending  at  the  spot  where  the  lateral  sinus  turns  back- 
wards. These  two  cuts  are  then  to  be  united  by  a  third  cut  wliich 
should  divide  the  crista  ossis  petrosi  perpendicularly  about  one  line 
behind  the  point  of  union  of  the  posterior  and  middle  third  of  the 
crista. 

If  it  is  desirable  to  remove  both  temporal  bones  the  same  proced- 
ure is  to  be  carried  out  on  the  other  side.  If  only  one  petrous  bone 
is  to  be  removed  the  two  openings  which  were  made  with  the  chisel 
at  the  beginning  are  united  by  a  medial  cut,  the  loosened  bone 
seized  with  forceps,  raised  up  and  dissected  from  the  soft  parts. 

II.  Dissection  of  the  Ear.  The  anterior  wall  of  the  external 
meatus  should  be  removed  with  scissors  and  gouge-forceps  up  to 
the  membrana  tympani.  The  osseous  roof  of  the  mastoid  cells,  of 
the  tympanum  and  of  the  osseous  Eustachian  tube  should  then  be 
chipped  away  with  the  gouge-forceps,  or  a  small  hook-shaped  knife. 
The  cartilaginous,  muscular  Eustachian  tube  should  be  opened  from 
its  pharyngeal  orifice.  For  a  thorough  examination  of  the  tym- 
panum, including  the  ossicula,  membrana  tympani,  tympanic  mus- 
cles and  nervus  facialis,  the  mode  of  procedure  is  as  follows  :  the 
tendon  of  the  musculus  tensor  tympani  and  the  articulation  of  the 
incus  and  stapes  should  be  divided  by  a  delicate  knife  ;  the  pyramid 
should  then  be  separated  from  the  osseous  structures  surrounding 
the  drum  membrane  and  external  meatus  by  sawing  parallel  with 
the  crista  ossis  petrosi  nearly  but  not  quite  into  the  tympanum  ; 
this  cut  should  begin  behind  the  styloid  process  and  run  along  the 
anterior  wall  of  the  canalis  caroticus.  A  light  blow  with  a  chisel 
in  the  cut  thus  made  with  the  saw  will  now  separate  the  portions 
of  bone.     The  soft  structures  can  then  be  dissected. 

To  examine  the  inner  ear  rapidly,  saw  along  the  whole  length  of 
the  pyramid  parallel  with  the  crista  ossis  petrosi  through  the  vertex 
of  the  upper  semicircular  canal ;  this  cut  runs  along  the  posterior* 
wall  of  the  canalis  caroticus.  Draw  out  from  the  porus  acusticus  in- 
ternus  the  facial  and  auditory  nerves  and  examine  the  exposed  coch- 


DISSECTION  OF   THE  EAR.  7 

lea  and  vestibule.  For  a  more  accurate  examiuation  of  the  inner 
ear  remove  the  roof  of  the  porus  acusticus  internus  with  the  i^ouo-e- 
forceps,  then  open  the  vestibule  from  above  by  a  small  hand-trephine. 
After  opening  the  osseous  semicircular  canals  divide  the  membra- 
nous canals  with  scissors  and  remove  from  the  vestibule  the  mem- 
branous utricle  together  with  the  membranous  semicircular  canals.^ 
Expose  the  cochlea,  which  is  bounded  anteriorly  and  inwardly  by 
the  fundus  of  the  porus  acusticus  internus,  by  gradually  chipping 
away  the  bony  mass  surrounding  it. 

Besides  the  above  method  of  Lucse  minute  directions 
for  dissection  of  the  ear  have  been  given  by  Toynbee,^ 
Yon  Troeltsch/  VoltoHni/  Wendt,^  and  others  which 
can  be  recommended  to  the  beginner  as  standard 
procedures.  The  great  difficulty  of  the  dissection  is 
first  met  in  the  ipner  ear,  and  can  only  be  overcome 
here  by  great  patience  and  practice.  The  membra- 
nous tissues  of  the  labyrinth  retain  their  structure 
much  longer  than  is  usually  supposed  ;  in  the  prepa- 
ration of  these  tissues  a  light  yellow  solution  of  potass 
chromate,  or  Mullers  fluid,  is  recommended  for  their 
preservation.  I  recommend  the  following  method  of 
procedure  as  very  well  adapted  to  the  examination 
of  the  inner  ear  :  — 

Tlie  trunk  of  the  auditory  nerve  is  followed  to  the  point  of  sub- 
division by  breaking  away  the  meatus  auditorius  internus  above  it. 
In  a  microscopical  examination  of  the  nerve  it  is  recommended  that 
it  be  compared  with  other  nerve  trunks  (fticialis).  The  vestibule 
and  cochlea  should  be  opened  from  above  by  gradually  chipping 
away  the  osseous  roof  with  a  chisel.     The  vestibule  lies  laterally 

1  See  the  method  described  in  Yirchow's  ArcTdv,  vol.  xxix. 

2  Toynbee,  Diseases  of  the  Ear,  p.  6. 

3  Von  Troeltsch,  Yirchow's  Archiv,  xiii.,  513.  Lelirhuch  der  Ohren- 
heilkunde,  6  Aufl.,  S.  587. 

*  Yoltolini,  Zerlegung  und  Unlersuchung  des  Gehororgans  an  der  Leiche. 
Habilliationsschrift,  Breslau,  1862. 

^  Wendt,  Archie  fiir  Heilkunde  von  E.   Wagner,  xiii.,  S  120. 


8  PATHOLOGY  OF   THE  EAR. 

from  the  facial  nerve,  that  is,  towards  the  squamous  bone.  Before 
reaching  the  vestibule  the  upper  semicircular  canal  will  be  opened 
and  the  membranous  canal  should  be  cut  through  and  drawn  out. 
After  laying  open  the  vestibule  the  membranous  labyrinth  is  ex- 
posed and  should  be  removed  with  the  other  semicircular  canals. 
As  soon  as  the  osseous  roof  of  the  cochlea  is  chiselled  away  the  base 
of  the  modiolus,  which  lies  towards  the  porus  acusticus  internus, 
should  be  broken  off,  and  the  whole  cochlea  with  the  spiral  lamina 
lifted  out.  A  careful  dissection  with  needles  is  necessary  for  this. 
The  contents  of  the  cochlea  thus  removed  should  now  be  placed  in  a 
one  per  cent,  solution  of  salt,  aqueous  humor,  or  perosmic  acid,  0.1- 
1  per  cent.,  and  laid  aside  for  microscopical  examination. 

There  remains  now  only  to  examine  the  plate  of  the  stapes  and 
to  expose  the  membrana  tympani  secundaria  on  its  inner  surface. 
The  sawing  open  of  the  whole  pars  petrosa  should  be  avoided  if  it 
is  desirable  to  obtain  a  knowledge  of  the  finer  relations  of  the  parts. 
The  use  of  the  saw  is  only  allowable  for  the  removal  of  the  petrous 
bone  from  the  skull,  and  should,  as  far  as  possible,  be  confined  to 
this.  The  fret-saw  for  the  removal  of  the  bone  from  the  base  of 
the  skull  has  the  disadvantage  that  it  is  very  easily  broken,  and  its 
use  requires  great  practice.  Compass-saws  are  better  adapted  for 
the  work,  but  the  soft  structures  are  too  easily  crushed  by  them. 
The  most  useful  instruments  are  chisel  and  hammer,  Liier's  gouge- 
forceps,  and,  for  the  finer  work  on  the  bone,  a  graver. 

THE    TEMPORAL    BONE. 

Malformations.  In  the  peculicarities  of  formation  in 
the  temporal  bone  numerous  individual  differences 
exist,  some  of  which  are  unimportant,  while  on  some 
others  it  is  possible  that  the  fate  of  the  individual 
may  depend.  They  may  form  the  foundation  for  a 
hereditary  predisposition  to  certain  diseases  of  the 
ear  itself,^  or  also  favor  fatal  secondary  disease  of  the 
brain. 

1  From  a  hereditary  unfavorable  formation  of  the  osseous  middle  ear, 
(Von  Trot'ltsi-h).  A  slight  depth  of  the  niches  of  the  labyrinthine  fone?i- 
tra3    favors   the    retrogression  of   the  swelling   and  duplicatures  of   the 


THE    TEMPORAL  BONE.  9 

A  complete  absence  of  the  whole  temporal  bone  is 
never  found,  but  in  some  monsters  a  union  of  the  two 
ears  is  seen,  and  in  double  monsters  with  a  single 
head  there  may  be  a  reduplication  of  the  temporal 
bones.^ 

In  hydrocephalus  the  temporal  bone  is  turned 
downwards  and  arched ;  the  meatus  is  directed  down- 
wards. 

Defects  of  certain  parts  from  arrest  of  development 
are  very  common,  on  one  or  both  sides.  They  may 
embrace  all  or  only  certain  portions  of  the  ear  (most 
frequently  the  external  and  middle  ear),  while  the 
other  portions  are  well  developed.  With  a  well- 
formed  external  ear  there  may  be  arrest  in  the  devel- 
opment of  the  inner  ear  and  nice  versa? 

Ossification  Defects  (rarefaction,  opening)  are  among 
the  most  common  inherited  irregularities.  They  are 
especially  frequent  in  the  tegmen  tympani  ^  with  a 
perfectly  normal  dura  mater,  but  are  also  found  in 
the  canalis  caroticus,  in  the  canalis  facialis,  in  the 
floor  of  the  tympanum,  in  the  cortical  substance  of 
the  processus  mastoideus,  in  the  osseous  roof  of  the 
superior  semicircular  canal,  and  in  the  form  of  a 
fissure  of  the  squamous  portion  of  the  bone;  in  el- 
derly persons  they  are  also  seen  in  the  form  of  pits 

mucous  membrane,  wlule  a  greater  depth  of  these  niches,  particuhirly  of 
the  fenestra  oralis,  is  unfavorable  for  this  healing  process. 

^  Carl  Langer,  Zur  Anatomie  des  Gehororgans  doppelleihlger  Missge- 
hurten.     Oesterr.  Med.  Wochenschrift,  1846,  No.  21. 

2  The  earlier  observations  on  malformations  of  the  temporal  bone,  up 
to  the  year  1837,  are  collected  in  Lincke's  Handbuch  der  Ohrenlie'd- 
kiinde,  i.,  582-611.  For  the  later  literature  see  p.  28,  under  "Au- 
ricle." 

3  Instead  of  absolute  gaps  in  the  bony  tissue,  the  roof  of  the  tym- 
panum often  contains  cavities  filled  with  reddish  gelatinous  tissue. 


10 


PATHOLOGY  OF   THE  EAR. 


in  the  course  of  the  fissura  petroso-squamosaj  and  on 
the  inner  snrfoce  of  the  squamous  bone,  where  they 

reach  the  size  of  a  bean, 
and  in  their  position  cor- 
respond to  the  Pacchio- 
nian bodies.  Aside  from 
the  possibihty  of  mistak- 
ing these  defects  in  ossifi- 
cation for  carious  destruc- 
tion they  have  a  great 
practical  importance  be- 
cause they  favor  the  ex- 
tension of  inflammatory 
processes  from  the  ear  to 
the  brain. 

Pneumaticity  of  the  pars 
petrosa  is  understood  to 
be  the  existence  of  anom- 
alous cavities  in  the  bone. 

Congenital  Defect  of  the  Bone  on    the  ^^,|^-^1^    ^^.^    f^^lecl    with    air 
upper  surface  of  the  pars  petrosa  near  its 

apex,  and  also  in  the  sigmoid  shius;  otitis  Or    witll    a    gclatiuOUS    red 

media  purulenta  acuta  without  perforation  x-  ThpV  SUrrOUnd  the 

of  the  drum  membrane,  resulting  in  fatal  LlSSUC.      1  UCy  SUrrOUnU  lUe 

basilar  meningitis,     a.  Porus  acusticus  in-  labvriuth  OU  all  sidcS,   CX- 

ternus.     b,  c.  Gaps  in  the  upper  surface  ,       "t  i      ii 

of  the  petrous  bone.    d.  Gaps  in  the  sulcus  tcnduig  CVCU  tO  thc  UppCr 

transversus.  ^yr^\\  of  the  mcatus  audi- 

torius,  and  are  in  direct  connection  with  the  mastoid 
cells. 

Hypersemia  of  the  petrous  bone  in  which  the  tissue 
of  the  bone  is  very  rich  in  blood,  and  when  looked 
at  through  the  dura  mater  often  appears  of  a  bluish 
red  color,  is  very  common  m  typhus,  and  is  also  seen 
in  variola. 

A  general  atrophy  of  the  bone,  in  which  it  appears 


THE   TEMPORAL  BONE.  11 

abnormally  light  in  weight  and  fragile,  occurs  in  old 
age  and  with  lues,  tumors  of  the  brain,  and  from  other 
unknown  causes  (for  instance,  in  connection  with  an- 
chylosis of  the  stapes). 

Osteoporosis  occurs  in  old  age  and  produces  open- 
ings in  the  bone  of  the  anterior  wall  of  the  meatus 
(Von  Troeltsch). 

Hyperostosis,  in  which  the  temporal  bone  appears 
very  heavy  and  massive,  its  processes  larger  and 
fuller,  its  openings  and  capillary  canals  smaller  and 
narrower  than  natural,  is  generally  combined  with  a 
universal  hyperostosis  of  the  skull  (syphilis,  old  age), 
but  it  may  be  confined  to  certain  parts  of  the  petrous 
bone,  as  the  meatus  extern  us,  processus  mastoideus, 
tuba  Eustachii,  canalis  caroticus,  and  it  is  then  fre- 
quently the  result  of  continuous  hypersemia  and  long 
existing  suppurative  processes  (with  caries). 

If  the  hyperostosis  is  the  result  of  ossifying  perios- 
titis in  foetal  life  or  early  childhood,  it  always  leads  to 
great  deafness  and  deafmutism.  The  labyrinthine 
fenestrge  are  then  found  closed  by  ossification,  the 
ossicula  anchylosed  into  one  mass,  the  labyrinthine 
cavities  diminished  in  size,  deposits  of  lime  lie  in 
the  meatus  internus  and  on  the  saccule  of  the  ves- 
tibule, etc. 

Friedreich  ^  describes  a  hyperostosis  of  the  petrous 
bone  in  a  case  of  congenital  unilateral  hypertrophy 
of  the  head. 

Caries  and  Necrosis. 

Literature  up  to  1830  will  be  found  in  Lehrbuch  der  Pathologischen 
Anatomic  von  Olto.  S.  174.  —  Krukenherg,  Jahrbiicher  der  Ambulator. 
Klinik  zu  Halle.    Bd.  II.     S.  203-252.    Halle,  1824.  —Wulzer,  Schmidt's 

1   VircJioio's  Archiv,  28,  Heft  5  and  6. 


12 


PATHOLOGY  OF   THE   EAR. 


Jalirb.  1834.  S.  344.  —  Bricheteau,  Arch.  Gen.  1834.  December. — 
WUlemier  (resp.  Scliroder  van  der  Kolk),  Diss.  Inaiig.  Utrecht,  1835. — 
CruveiUiier,  Anat.  Patholog.  du  Corps  Hiimain.  1835-1842.  II.  Vol.  33. 
Livraison.  Mahxdies  du  Cerveau.  —  Albers,  Ueber  Otorrhoe,  Grafe's  und 
Walther's  Journal.  1836.  —  Hamilton,  Dublin  Journ.  1841.  —  Hughes, 
Lancet.  1841.  —  Smith,  Dublin  Journ.  1841.  —  Guckelherger,  Zeitschi'. 
f.  Chir.  und  Geburtsk.  VII.  3.  l^bl.  —  Wolf,  Preuss.  Vereins-Ztg.  1857. 
Nos.  35,  36.  —  Meniere,  Article  on  Bony  Sequestra  observed  in  the  differ- 
ent Parts  of  the  Ear.  Gaz.  Med.  de  Paris.  1857.  No.  33.  —  Hutchinson, 
Canstatts  Jahresber.  1861.  3.  S.  50.  —  /.  6>w&er,  Wien.  Med.  Halle. 
1863. —  OJe?iiM.s,  Medicinske  Arch.  III.  1.  1866. —  Von  Troeltsch,  Anat. 
Beitrage  zur  Lehre  von  der  Ohreneiterung.    Arch.  f.  O.    IV.    S.  97-142. 

1869.  —  /.     Gruher,    Zur 

Casuistik    der    Schliifen- 

/  "^-^"~-^  bein-Necrose.     M.   f.   O. 

1874.  No.  9.  (Case  of 
loss  of  the  whole  annulus 
tympanicus  and  a  portion 
of  the  squama  through  the 
external  meatus,  in  a  child 
two  years  old.)  —  Boeters, 
Necrose  des  Gehorlaby- 
rinths.  Diss.  Inaug.  Halle, 

1875.  —  Also  the  already 
quoted  text  books  of  otol- 
og\'  and  the  sjX'cial  jour- 
nals. 

Caries,  or  ulcer- 
ative  ostitis,  at- 
tacks,   of   all    the 
bones  of  the  skull. 
Fig.  2.  the  temporal  bone 

Carious  Perforation  of  the  Anterior  Wall   of  the    mOSt  frequently ;  it 

is  very  often  bilat- 


Pyraniid  at  the  spot  where  the  pars  petrosa  of  the 
temporal  bone  passes  into  the  pars  squamosa.  Cor- 
responding with  this  spot  on  the  lower  surface  of  the  eral  ancl  aSSOciatCCl 
dura  mater  were  masses  of  granulations,  the  upper 
surface  of  the  dura  mater  being  unchanged.  Death 
from  pyemia.  For  history  and  dissection,  see  Archiv 
fiir  Ohrenheilk.,  II.,  S.  36. 


with  simultaneous 
caries  of  other 
bones  of  the  skull. 
The  points  of  preference  for  caries  are  the  mastoid  pro- 
cess, the  median  portion  of  the  upper  posterior  wall 


THE    TEMPORAL   BONE. 


13 


of  the  meatus  (floor  of  the  antrum  mastoideum),  and 
the  walls  of  the  tympanum,  preferably  its  roof;  less 
frequently  the  pars  petrosa  is  attacked  and  least  fre- 
quently the  meatus  auditorius  internus.  Exception- 
ally extensive  caries  can  exist  in  the  petrous  bone. 


Caries  Necrotica.  In  the  carious  cavity  ff,  is  a  loose  sequestrum,  consisting  of 
tlie  greater  part  of  tlie  jn'ramid.  b.  Nervus  acusticus.  c.  Processus  conch'loideus 
of  the  lower  jaw.     (/.  Dura  mater,  with  granulation-growths  upon  it,  turned  back. 

tympanum,  tuba,  mastoid  process,  and  even  in  the 
external  meatus,  and  yet  the  membrana  tympani 
remain  entire,  and  the  ossicles  continue  in  their 
position.^  Usually,  however,  the  drum-membrane 
shows  a  loss  of  substance  or  is  wholly  destroyed. 
The  dura  mater  covering  the  bone  is  generally  thick- 

.  1  Already  proven  by  old  observations:  Lieutard,  Hist.  Anat.  Med.,  vol. 
ii.,  lib.  iii.,  observ.  108.     Kuh,  Klinische  Beitrdge,  etc.,  Fall  2,  S.  20. 


14  PATHOLOGY  OF   THE  EAR. 

enecl,  is  frequently  but  slightly  attached  to  the  bone 
and  discolored  ;  on  removing  it  granulations  are 
found  attached  to  its  inner  surface,  which  fill  up 
the  carious  openings  in  the  osseous  substance. 

The  caries  is  generally  the  secondary  result  of  an 
acute  or  chronic  suppuration  of  the  soft  tissues  of  the 
ear,  which  has  extended  to  the  surrounding  bone  ; 
seldom  is  it  the  result  of  suppurative  ostitis  or  pri- 
mary periostitis.  Usually  the  ulcerative  process  ex- 
tends from  the  surface  deeper  and  deeper  into  the 
substance  of  the  bone.  Frequently  on  dissection  pro- 
cesses of  demarcation  are  seen,  osteosclerosis  or  osteo- 
phytes. 

Necrosis  is  less  common  than  caries;  it  attacks 
most  frequently  the  mastoid  process,  the  lower  wall 
of  the  external  meatus,  the  ossicula  and  the  pyramid. 
Sometimes  the  squamous  portion  of  the  bone  is  alone 
attacked  by  necrosis  and  may  be  thrown  off  in  toto. 
Cases  have  even  been  reported  where  almost  the 
whole  temporal  bone  has  been  thrown  off  by  necrosis 
with  retention  of  life. 

The  most  common  fjital  results  from  these  processes 
are  purulent  meningitis,^  abscess  of  the  brain,^  sinus- 
phlebitis  with  p3^a3mia,^  or  combinations  of  these  dis- 

1  Guckelberger,  1.  c.  Hinton,  Med.-Chir.  Transactions,  xxxix.,  p.  101, 
1856.  Von  Troeltsch,  Virchoio's  Arch'w,  xvii.,  S.  14.  Yoltolini,  Ihid., 
xviii.,  S.  2.  Ulmer,  Wiener  Med.  Halle,  1861,  S.  40,  41.  Ockel, 
Petershurger  Med.  ZeitscJtrift,  1862.  Wendt,  Archiv.  filr  Phjs.  Heil- 
kunde  von  Wagner,  1870,  etc. 

2  Lebert,  VircJioiu's  ArcJiii\  x.  Von  Troeltsch,  Ibid.,  xvii.,  S.  42.  Gull, 
Guy's  Hospital  Reports,  1858.  Gruber,  Zeitschr.  der  Wiener  Aertze,  1860. 
Schott,  Wurzh.  Med.  Zeitschr.,  1861,  S.  462.  R.  Meyer,  Pathologic  des 
Gehirnabscesses,  Zurich,  1867;  eighteen  cases  following  caries  of  the  pe- 
trous bone,  fourteen  on  the  right,  four  on  the  left  side.   Wendt,  1.  c,  etc. 

3  Lallemand,  Lcttres,  iv.  §  36.     Bruce,  London  Med.  Gaz.,  vol.  xxvii., 


THE    TEMPORAL  BONE. 


15 


eases.  Much  less  common  are  fatal  hemorrhages  from 
carious  perforation  of  the  canalis  caroticus  with  ero- 
sion of  the  carotis  cerebralis/  of  the  arteria  meningea 


Fig.  4. 
Necrosis   of   the  Pyramid,    a.  Sinus   transversus.     i.  Nervus  acusticus.     c.  Se- 
questrum slightly  movable  on  firm  pressure,     d.  Probe  in  an  opening  of  the  laby- 
rinthine cavity,   e.  Apex  of  the  pyramid.   Death  from  abscess  in  the  cerebellum. 

p.  608  (an  atlmirable  article).  Sedillot,  De  V Infection  Purulente,  1S48. 
Toynbee,  Med.-Chir.  Transactions,  1851,  vol.  xxxiv.  Lebert,  Ueher  Ent- 
zilndunf/  der  Hirnsinus.  Virchow's  Arch.,\yL.,  1855.  Heussy,  Ziiricb,  1855. 
Weill,  Strassburg,  1858.  Von  Duscb,  Zeifschr.f.  Rat.  Med.,  1859.  Colin, 
Klinik  der  Embolischen  Gefdsskrankheiten,  Berlin,  1860.  Von  Troeltsch, 
VircJioto's  Arch.,  xvii.,  1,  2.  Gruber,  Wiener  Wochenbl.,  1862,  Nos.  24, 
25.  Lancereaux,  De  la  Thrombose  et  de  VEmloUe  Cerebrate,  Paris,  1862. 
Griesinger,  Arch,  fur  Phys.  Heilkunde,  1862.  Schwartze,  A.  f  0.,  vi., 
S.  219.  Politzcr,  Ibid.,  viii.,  S.  288.  O.  Heubner,  Arch,  fiir  Phys.  Heil- 
kunde, ix.,  1868.  AVreden,  Petersb.  Med.  Zeitschr.,  xvi.,  5,  S.  61-137. 
Wendt,  Arch,  filr  Heilkunde  ron  Wagner,  xi.,  S.  562. 

1  Kimmel,  Observatio  Anat.  Patholog.  de  Cnnali  Carotico  Carie  Syphi- 
litica Exeso,  Lipsiae,  1805,  witb  an  illustration.  Boinet,  Arch,  de  Me'd., 
1837.   Lavacherie,  Bulletin  de  I' Acad,  de  Med.,  1848,  vol.  vii.,  p.  789.    San- 


16 


PATHOLOGY  OF   THE   EAR. 


media,  of  the  large  venous  sinuses  or  of  the  bulbus 
venae  jugularis. 

By  which  channels  the  extension  of  the  purulent 
inflammation  takes  place  frequently  remains  uncertain 
at  the  autopsy ;  in  many  cases  it  probably  takes  place 
along  the  course  of  the  veins  (aqua^cluctus  vestibuli 
and  cochleae),  along  the  folds  of  the  dura  mater  which 
_  extend  into  the  fissura 

p  e  t  r  o  s  o  -  s  q  u  amosa, 
along  the  neurilemma 
of  the  acusticus  or  fa- 
cialis, and  also  along 
the  connective  tissue 
of  the  capillary  blood- 
vessels which  perfor- 
ate the  bone  in  all 
directions  (tegmen 
tympani,  hiatus  sub- 
arcuatus). 

Sometimes    death 
results    from    severe 


where  it  is  impossible 


Fig.  5. 

Caries  of  tlie  Sulcus  Transversus  produced  by    b  r  a  i  U     S  y  Ul  p  t  O  Ul  S 
a  very  extensive  caries  of  the  mastoid  pi-ocess. 
The  sinus  transversus  was  very  much  thinned, 
but  without  ulceration.     (From  Toynbee,  "  Dis-    tO  fiud  any  tiling  UlOre 
eases  of  the  Ear,"  p.  327.)  ,i      i        •       i        •  ,i 

pathological  in  the 
brain  than  oedema,  the  causal  connection  of  which 
with  the  ear-disease  is  perhaps  very  improbable. 

tesson,  Htjgiea,  Bd.  xiv.,  1855.  Cliassaignac,  Trnite  de  la  Suppuration, 
vol.  i.,  p.  529.  Gaz.  des  Hop.,  1857,  p.  226.  Marc  See,  Bullet,  de  la 
Soc.  Anal,  de  Paris,  1858,  p.  6.  Toynbee,  Med.-Chir.  Transactions,  xliii., 
p.  217  to  224,  1861.  Baizeau,  Gaz.  des  Hop.,  1861,  p.  350.  Todlliche 
Ohrhlulung  hei  Sypliil.  Caries,  Deutsche  Klinik,  1863,  No.  23.  Boeke, 
Pestli.  Med.  Chirwg.  Presse,  x.,  28.  A.  Hermann,  Wien.  Med.  Woclien- 
schrift,  xvii.,  30-32.  Pilz  (Billroth),  Diss.  Iiuiitg.,  Berlin,  1865.  Broea, 
Gaz.  des  Hop.,  1866,  No.  53,  p.  240.  Hynes,  The  Lancet,  1870,  No.  13. 
Jollv,  Arch.  Ge'ner.  de  Mtd.,  1870,  March. 


THE    TEMPORAL   BONE.  17 

Of  late  years  the  views  of  the  relations  of  caries  to 
abscess  of  the  brain  have  been  decidedly  modified. 
Formerly  it  was  generally  thought  that  the  brain- 
abscess  was  the  primary  lesion,  and  that  the  pus 
sought  an  exit  for  itself  through  the  cavum  tym- 
pani ;  ^  and  it  was  considered  to  be  the  rule  only  in 
very  exceptional  cases  that  the  caries  of  the  ear  was 
the  primary,  and  the  abscess  of  the  brain  the  second- 
ary lesion  ;  to-day,  however,  it  is  almost  universally 
considered  that  the  facts  are  just  the  reverse. 

The  first  who  asserted  this  with  confidence  was 
Morgagni.^  He  declared,  that  in  the  majority  of  cases 
the  brain  aftection  was  only  the  result  of  the  caries 
extending  into  the  cavity  of  the  skull.  The  opposite 
process,  a  suppuration  within  the  skull  making  an 
outlet  for  itself  through  the  ear,  although  it  may  per- 
haps occur,  is  certainly  very  rare. 

Only  a  few  authors,  as  Odenius,^  now  hold  to  the 
correctness  of  the  old  theory  for  exceptional  cases. 
The  possibility  of  an  abscess  in  the  cerebrum  or  cere- 
bellum discharging  itself  through  the  temporal  bone 
(otorrhoea  cerebralis,  Itard),  cannot  certainly  be  de- 

^  Otto,  Sellene  Beohachtungen,  etc.,  il,  S.  97,  savs:  "The  abscess, 
■which  I  liave  always  found  only  in  the  nii(hlle  cerebral  lobe  and  never  in 
the  cerebellum,  lies  at  the  lowest  point  of  the  whole  brain,  and  the  pus 
must  therefore,  from  the  law  of  gravity,  sink  and  work  its  way  through 
the  bone." 

This  theory  of  an  opening  of  a  brain  abscess  into  the  tympanic  cavity 
from  destruction  of  its  roof  or  of  the  mastoid  cells,  is  found  even  in  Rokit- 
ansky,  3  Aufl.,  Band  1,  2,  S.  460,  1855. 

2  1.  c,  I.,  ep.  xiv.,  art.  6. 

^  The  case  quoted  by  Odenius  in  support  of  his  theory  is  as  follows: 
After  injury  to  the  head  an  abscess  in  the  right  cerebellum  with  pachy- 
meningitis ;  on  the  pars  petrosa  there  was  a  superficial  ulceration  at  the 
external  opening  of  the  aqua;ductus  vestibuli  while  the  inner  ear  showed 
only  very  slight  signs  of  disease.  Medicinske  Archiv,  iii.,  i.,  No.  4. 
2 


18  PATHOLOGY  OF   THE   EAR. 

nied,  since  abscesses  of  the  brain  sometimes  seek  an 
outlet  for  the  pus  in  other  parts  of  the  skull  through 
natural  or  fistulous  openings  (ethnoid,  frontal,  sphe- 
noid, and  parietal).  The  assertion  of  Lallemand  that 
the  pus  of  a  brain-abscess  never  seeks  an  outlet  at 
any  other  spot  than  the  ear,  is  incorrect.  The  facts 
are  that,  as  a  rule,  the  abscess  of  the  brain  is  second- 
ary and  the  result  of  suppuration  in  the  ear  pro- 
duced by  an  inflammation  of  the  veins.  It  should  not 
be  forgotten,  however,  that  abscess  of  the  brain  and 
disease  of  the  ear  may  occur  simultaneously  from  the 
same  cause  (trauma),  as  has  already  been  shown  by 
Albers.  Abscesses  of  the  brain  from  otitis  are  situated 
in  the  temporal  lobes  of  the  cerebrum  or  in  the  cere- 
bellum, more  frequently  on  the  right  side. 

Heusinger^  found  in  one  case  double  abscess  in 
the  posterior  lobe  of  the  cerebrum  and  in  the  cerebel- 
lum with  thrombus  of  the  right  lateral  sinus,  the 
development  of  wdiich  had  been  unsuspected.  Ab- 
scess of  the  brain  frequently  occurs  without  being  in 
direct  connection  with  the  carious  mass. 

Von  Troeltsch  and  Magnus,^  each  in  one  case,  found 
an  abscess  of  the  brain  on  the  opposite  side  from  the 
affected  ear.  In  such  cases  it  has  been  supposed  by 
some  that  the  abscess  was  caused  by  metastasis  (em- 
bolus) from  the  carious  spot ;  while  by  others  all  con- 
nection between  the  abscess  and  the  caries  has  been 
denied,  and  tuberculosis  of  the  lungs  was  regarded  as 
the  cause  of  the  brain-abscess  (infection  of  the  brain 
from  a  gangrenous  cavity).  Finally,  the  possibility 
of  the   accidental  coincidence   of  the   very   frequent 

1   Virchoto's  Arch.,  xi.,  S.  92. 
^  A.f.O.,  .xi.,  S.  293. 


THE    TEMPORAL  BONE.  19 

caries  of  the  temporal  bone  with  an  idiopathic  abscess 
of  the  brain  has  been  accepted  by  others,  as  was  long- 
since  sucrs-ested  by  Abercrombie. 

Exceptionally  cases  occur  where  instead  of  an  ab- 
scess a  tumor  of  the  brain  ^  is  found  with  chronic 
otitis. 

Both  dissection  and  frequent  clinical  experience 
show  that  caries  of  the  temporal  bone  often  heals. 
If  the  labyrinth  is  exempt  from  the  caries  loss  of  the 
hearing  may  not  occur,  but  a  very  considerable  de- 
gree of  the  hearing  may  remain,  depending  on  the 
extent  and  location  of  the  carious  destruction. 

Fractures  of  the  base  of  the  skull  often  reach  the 
temporal  bone  and  allow  a  discharge  of  the  liquor 
cerebro-spinalis  if  they  have  extended  into  the  laby- 
rinth or  the  porus  acusticus  internus,  into  which  the 
subarachnoid  cavity  enters  with  the  dura  mater  and 
arachnoid.  A  rupture  of  the  membrana  tympani  and 
bleeding  from  the  ear  is  usually  associated  with  such 
a  fracture,  but  not  always.  In  the  latter  case  the 
cerebro-spinal  fluid  may  ooze  out  through  a  fissure  of 
the  osseous  canal.  Sometimes  the  fissure  extends 
through  both  petrous  bones,  even  when  tlie  injury 
has  taken  place  only  on  one  side  of  the  head.'^  The 
injuries  which  are  found  on  careful  preparation  of  the 
petrous  bone  are  naturally  very  variable.  Wendt,  for 
example,  found  in  one  case  not  only  fracture  of  the 
base  of  the  stapes  and  the  bridge  of  bone  lying  be- 
tween the  oval  and  round  fenestra?,  but  also  brain 
substance   in    the    vestibule    and    tympanum.     It    is 

1  Bright,  Giqi'x  Hospital  Reports,  ii.,  1857.  p.   279,  2  cases.     Fischer, 
(case  from  Traube's  Clinic),   Charitc'-Annalen,  1863. 

2  Case  by  Yoltolini,  M.  f.  0.,  1869,  S.  110. 


20  PATHOLOGY   OF   THE  EAR. 

well  known  that  brain  substance  may  be  forced  out 
through  the  meatus. 

The  usual  result  of  fractures  of  the  petrous  bones 
is  death  from  inflammation  of  the  brain  and  its  mem- 
branes which  may  only  develop  several  weeks  after 
the  injury.  If  the  reactive  inflammation  is  not  fatal 
total  deafness  remains.  If  inflammation  of  the  menin- 
ges does  not  occur  the  fracture  may  heal,  seldom  by 
osseous  consolidation  but  more  frequently  by  fibrous 
union.  This  possibility  has  been  confirmed  by  trust- 
worthy dissections.^ 

New  Growths.  Exostoses  arising  from  the  temporal 
bone  and  projecting  into  the  cavity  of  the  skull  have 
been  described  by  several  authors,  Petit,  Cruveil- 
hier,-  Toynbee.^ 

R.  Yolkmann*  has  figured  one  of  immense  size 
from  the  pathologico-anatomical  museum  in  Halle ; 
it  existed  simultaneously  with  sclerotic  thickening  of 
the  bones  of  the  skull. 

Smaller  exostoses  within  the  cavities  of  the  ear  are 
common  ;  they  are  most  frequent  in  the  meatus  ex- 

1  See  Langenbeck's  Archiv,  vi.,  S.  576.  Deafness  and  facial  paraly- 
sis on  the  left  from  a  fall  on  the  left  side  of  the  occiput.  Recovery. 
Death  from  tuberculosis  seven  months  afterwards.  Anatomical  appear- 
ances: on  the  base  of  the  skull,  corresponding  to  a  fissure  at  that  spot,  a 
yellowish,  rusty-brown  discoloration;  a  new  growth  of  connective  tissue 
in  the  brain;  the  origin  of  the  nervus  acusticus  sinister  in  the  fourth  ven- 
ticle  less  white  than  on  the  right  side  and  infiltrated  with  numerous  cor- 
pora amylacea;  the  nerve  fibres  of  the  trunk  of  the  acusticus  normal. 
The  fissure  of  the  skull  passed  through  the  pars  tympanica,  through  the 
porus  acusticus  externus,  and  separated  the  mastoid  and  squamous  from 
the  petrous  portion  of  the  temporal  bone.  The  fjap  in  the  bone  loas  par- 
tially filled  hy  fibrous  tissue,  partially  by  a  mass  of  bone. 

2  A7iat.  Patholoq.,  ii.  Livraison,  xxvi. 
8  Catalogue,  No.  791. 

*  Knochenkrankheiten,  S.  429. 


THE    TEMPORAL  BONE.  21 

tenuis,  where  they  may  lead  to  complete  closure  of 
the  canal. 

The  condition  which  has  been  particularly  described 
by  French  authors  as  tubercle  or  tubercular  infiltra- 
tion ^  of  the  petrous  bone,  and  has  been  assumed  to  be 
a  frequent  cause  of  chronic  otitis  and  caries  in  phthis- 
ical persons,  corresponds  to  our  present  idea  of 
ostitis  caseosa.  The  masses  which  are  described  as 
tubercles  are  carious  cavities  in  the  bone  which  are 
filled  with  inspissated  pus.  Real  tubercles  in  the  pe- 
trous bone  are  very  rarely  seen  ;  they  do,  however, 
exist  and  have  recently  been  described  by  Zaufal.^ 

A  tubercular  mass  of  the  size  of  a  pigeon's  egg, 
which  I  once  found  on  the  porus  acusticus  internus, 
did  not  arise  from  the  petrous  bone  but  from  the  dura 
mater. 

In  pigs  primary  tuberculosis  of  the  temporal  bones 
occurs  not  unfrequently.^ 

Cholesteatoma. 

VircJioio,  Virch.  Arch.,  VIII.  S.  371.  —  Totjnbee,  Lond.  Med.  Gaz. 
1850.  Nov.  Med.-Chirur.  Transactions.  Vol.  xlv.  VII.  Series.  Diseases 
of  the  Ear.  1860.  —  6Vu/;e;-,  Allgem.  Wien.  Med.  Ztg.  1862.  Nos.  31, 
3.3.  — iy.  Fi'.'Jc/ier,  Charite-Annalen.  1865.  XIII.  S.  262. —PraW,  Diss. 
Inauor.  Berlin,  1865.  —  Bate maiui,  On  Cholesteatoma.  Arch,  of  Med. 
Vol.'lV.  1866.— Fon  Trneltsch,  A.  f.  O.  IV.  S.  99,  103,  106,  112,  118, 
127,  and  Lehrbuch.  6  Aufl.  S.  AQl.  —  Buhl  (Nobiling),  Bayr.  Aerztl. 
Intelligenzblatt.  1869.  No.  33.  Fall  4.  —  Zwrce,  Verhandl.  der  Berl. 
Med.  Gesellsch.  I.  (Sitzung  vom  26  Febr.  1873)  and  Arch,  fur  O.  VII. 
S.  Toi.—  Wendt,  Arch.  f.  Phvs.  Ileilkunde  von  Wagner.  XIV.  1873.— 
Sitzungsprotocoll  der  Section  fiir  Ohrenheilkunde  auf  der  Naturforscher- 
Vers.  in  Leipzig.     1873.      (Siehe  Arch.  f.  O.   VIII.   S.  215.) 

1  Rilliet  and  Barthez,  Traite  des  Mnlnd.  des  Enfants,  Bruxelles,  ii., 
p.  489.  Nekton,  Recherches  sur  V Affections  Tuherc.  des  Os,  Paris,  1837, 
pp.  46,  70.     Grisolle,  Pres^e  Med.,  1837,  No.  32. 

2  A.  f.  0.,  ii.,  S.  174. 

3  Schiitz,  Virchow'x  Arch.,  Band  66,  S.  93. 


22 


PATHOLOGY  OF   THE  EAR. 


Cholesteatoma  of  the  temporal  bone  (pearl  tumor, 
Yircliow  ;  molluscous  or  sebaceous  tumor,  Toynbee)  is 
a  name  often  used  for  various  pathological  conditions. 
In  some  of  the  least  common  cases  it  designates  a 
true  new  growth  arising  from  the  bone,  or  from  parts 
of  the  ear  (skin  of  the  meatus  externus,^  membrana 
tympani,"'  or  mucous  membrane  of  the  tympanum^) 


Fig.  6. 
Circumscribed  Atrophy  from  a  Cholesteatoma,  a.  A  large  opening  in  the  posterior 
wall  of  the  meatus  leading  into  a  closed  cavity,  of  the  size  of  a  walnut,  in  the 
pars  mastoidea,  with  perfectly  smooth  and  solid  walls,  b.  Entrance  to  the  tym- 
panum. At  the  sinus  lateralis  is  a  thin,  transparent  spot  of  bone.  The  corre- 
sponding temporal  bone  on  the  right  side  was  perfectly  normal. 

analogous  to  the  cholesteatoma  of  other  bones  of  the 
skull   (occiput,   OS  frontis),  brain,  or  meninges.      It 

^Toynbee,  Sebaceous  Tumora  in  the  Ext.  Auditory  Meatus.  Med.- 
Chirur.  Transact.,  vol.  xliv.  Schwartzo,  A./.  0.,  vi.,  S.  294  ;  Ibid.,  vii., 
2.59,  Note. 

2Hinton,  A.  f.  O.,  ii.,  S.  151.  Wendt,  A.  f.  Heilk,xix.,  Heft  6. 
Kiipper,  A.  f.  O.,  xi.,  p.  18. 

3  J.  Gruber  (/.  c). 


THE    TEMPORAL  BONE. 


23 


consists  of  a  thin  fibrous  capsule,  which  contains  a 
substance  resenibUno;  stearine,  and  o-listenino-  hke 
mother-of-pearl,  the  morphological  elements  of  which 
are  chiefly  flat  cells  of  polygonal  shape  (epidermal 
cells),  and  also  often,  but  not  constantly,  crystals  of 
cholesterine  in  small  numbers.  (According  to  Lucae, 
they  contain  also  nucleated  giant  cells.)  ^ 

In  those  cases  in  which  a  true  new  growth  ex- 
ists, all  inflammatory  irritation  in  the  neighborhood  is 
wanting  in  the  ear- 
lier stages  of  its  de- 
velopment, and  sup- 
puration with  a  de- 
structive tendency 
is  only  shown  later, 
when  we  may  luive 
perforation  of  the 
membrana  tympani, 
or  the  bone  of  the 
upper  wall  of  the 
meatus,  or  of  the  sul- 
cus transversus,  wdth 
opening  into  the 
middle  or  posterior 
fossa  of  the  skull. 

That  cholesteato- 
ma may  appear  as  a  true  new  growth  in  the  middle 
ear,  has  been  lately  fully  established  on  dissection  by 
Lucae/  as  he  found  with  the  growth  neither  inflamma- 
tion of  the  tympanum  nor  perforation  of  the  mem- 
brana tympani. 

^  R.  Volkmann,  Knochenkrankheiten,   S.  487,  places  the  cholesteatoma 
midway  between  cancroid  and  atheroma. 
-  l.'c. 


Circumscribed  Atrophy  of  the  Sulcus  Transver- 
sus from  cholesteotnma,  with  erosion  of  the  sinus 
(otorrhagia).  Antrum  mastoideum  and  tympanum 
with  smooth  walls,  and  much  enlarj^ed  by  atrophy 
from  pressure.  The  opening  into  the  sulcus  meas- 
ures 11  mm.  in  length  and  5-6  mm.  in  breadth, 
and  has  perfectly  smooth  edges. 


24 


PATHOLOGY  OF   THE  EAR. 


In  the  great  majority  of  cases  of  so-called  choles- 
teatoma in  the  temporal  bone,  we  are  dealing  with 
nothing  more  than  a  retention  of  inflammatory 
products,  the  result  of  suppurative  processes  (Von 
Troeltsch).  A  collection  of  concentric  layers  of  epi- 
dermis cells  and.  occasional  masses  of  cholesterine 
crystals  form  around  a  nucleus  of  fatty  and  caseous 
pus ;  the  connective  tissue  capsule  is  wholly  wanting. 
The  cause  of  these  collections  is  purulent  catarrh  of 
the  middle  ear,  with  polypoid  granulations  and  per- 
foration of  the  membrana  tympani. 

Such  collections  are  found  in  the  natural  cavities, 

most  frequent- 
ly in  the  an- 
trum mastoid- 
d  e  u  m ;  but 
they  may  ex- 
ist in  the  tym- 
panum, mea- 
tus externus, 
or  in  the  cav- 
ities of  the 
temporal  bone 
w  hi  c  h  have 
been  enlarged  or  freshly  excavated  by  the  pressure 
of  the  ma&'s.  In  this  way  the  whole  temporal  bone 
may  be  infiltrated  and  destroyed.  By  pressure  on 
the  neighljoring  tissues,  from  the  increase  in  the  col- 
lection and  from  its  swelling  by  absorption  of  mois- 
ture, or  by  the  retention  and  resorption  of  the  de- 
generated products  of  secretion,  serious  diseases,  and 
even  death  may  result  (purulent  sinus- thrombosis 
wath  pyoemia,  meningitis,  abscess  of  the  brain). 


Circumscribed  Atrophy  of  the  External  Meatus,  from  clio- 
lesteatoma. 


THE    TEMPORAL  BONE.  25 

From  time  to  time  parts  of  the  retention-tumor 
may  become  loosened  and  be  thrown  off;  this  is  usu- 
ally preceded  by  severe  pain  caused  by  the  swelling 
of  the  mass. 

The  flat  polygonal  cells,  which  generally  consti- 
tute the  chief  part  of  these  masses  and  of  the  whole 
tumor,  very  much  exceed  in  size  the  nornuil  pave- 
ment epithelium  of  the  tympanic  mucous  membrane, 
being  three  times  and  more  larger  (0.02-0.03  mm. 
in  diameter),  and  exactly  resemble  the  cells  of  the 
epidermis.  Their  apparent  w\ant  of  nuclei  is  not  real, 
as  the  nuclei  can  be  brought  out  clearly  by  treatment 
with  ammoniated  solution  of  carmine  (Lucae).  Be- 
tween the  cells  grains  of  fat  are  very  frequently  seen, 
and  sometimes  threads  of  fungus. 

The  source  of  these  large  flat  cells  has  been  often 
discussed.  Lucae  considers  that  the  epidermis  cells 
have  their  origin  on  the  granulations,  the  older  layers 
being  continually  thrown  off  and  gradually  collecting 
in  the  cavity  of  the  middle  ear.  On  this  account  he 
considers  that  the  removal  of  the  granulations  is  the 
chief  point  of  therapeutics.  Von  Troeltsch  has  some- 
times found  these  gigantic  flat  cells  in  the  normal 
covering  of  the  antrum  mastoideum,  most  commonly, 
however,  with  collections  of  pus  in  this  cavity,  and 
he  therefore  thinks  it  very  possible  that  under  patho- 
logical irritation  and  pressure  this  epithelial  surface 
develops  in  some  special  way.^  The  fact  is,  that  the 
tympanic  epithelium,  under  a  chronic  purulent  in- 
flammation with  defect  of  the  drum-membrane,  often 
assumes  the  characteristics  of  the  skin,  showing  a  rete 
Malpighii  and  epidermis. 

1  Lehrhuch,   S.  425. 


26  PATHOLOGY  OF   THE  EAR. 

Wenclt  considers  that  the  development  of  the  so- 
called  cholesteatoma  of  the  temporal  bone  is  due  to 
a  form  of  desquamative  inflammation  of  the  mucous 
membrane  of  the  middle  ear  (with  or  without  per- 
foration of  the  membrana  tympani),  the  epithelium 
of  this  mucous  membrane  assuming  an  epidernjal 
character,  and  developing  a  rete  Malpighii  during 
or  after  a  chronic  inflammatory  process.  Chronic 
inflammation  of  the  walls  of  the  meatus  may  lead 
to  the  formation  of  a  cholesteatoma,  if  the  exfoliated 
masses  get  into  the  middle  ear,  either  through  a 
perforation  of  the  drum-membrane,  or  through  an 
opening  in  the  osseous  walls  of  the  meatus. 

Malignant  Tumors  of  the  temporal  bone  are  not  com- 
mon, if  those  cases  are  excluded  in  which  tumors  of 
neighboring  parts  (parotid  gland,  base  of  the  skull, 
antrum  of  Highmore,  etc.)  have  led  to  secondary 
destruction  in  the  ear.  I  myself  have  seen  three 
cases  of  primary  epithelial  cancer  of  the  temporal 
bone,  of  which  two  have  been  reported,  and  in  all  of 
them  the  origin  of  the  growth  was  the  tympanic  mu- 
cous membrane.^ 

Fig.  9  shows  the  extent  of  the  destruction  of  the 
bone  in  one  of  these  cases,  seen  from  the  inside. 

A  list  of  all  the  malignant  tumors  known  to  me  is  confined  tc 
five  cases  described  by  Toynbee  ^  (carcinoma),  one  by  Gerliard  ^ 
(carcinoma  of  the  left  petrous  bone),  one  by  Billroth*  (without  au- 
topsy), two   by  Wilde  ^  (osteosarcoma),  one   by  Travers '^  (without 

1  Archiv  f.  Ohrenheilkunde,  ix..  S.  208,  215,  Note. 

^  Diseases  of  the  Ear,  cliap.  xvii. 

^  Jenaer  Zeitschi'.,  i.,  4. 

*  Arc/i.f.  Klin.  Chir.,  x..  S   G7.     Compare  also    A.  f.  0.,  v.,  S.  28. 

^  Pract.  Berne rliincjeiu  etc.,  S.  244. 

6  Froriep's  Nutizen,  Bd.  25,  No.  22,  S.  352. 


THE    TEMPORAL  BONE. 


27 


autopsy),  one  by  Boeke/  one  by  Wishart,^  one  by  Robertson  ^  (sar- 
coma). To  these  may  be  added  three  cases  by  Cruveilhier ;  *  two 
of  these,  althougli  described  under  the  name  "  tumeurs  fibreuses  du 


Fig.  9. 
Destruction  of  the  Temporal  Bone  by  Epithelial  Cancer,  a.  IMedian  remnant  of 
the  pars  petrosa  ;  on  the  superior  surface  of  its  apex  the  bone  is  also  destroyed 
by  the  new  growth,  h.  Porus  acusticus  internus.  c.  Foramen  lacerum  anterius. 
d.  Foramen  ovale,  enlarged  by  destruction  of  its  edges  to  twice  its  natural  circum- 
ference,    e.  Foramen  spinosum.    f.  Sphenoid  articulation. 

i-ocher,"  Rokitansky  considers  sliould  probably  be  regarded  as  can- 
cer, although  in  the  first  case,  Avhich  is  the  most  fully  described  and 
figured,  Cruveilhier  expressly  adds,  "  ne  presentait   pas  le  moindre 

1  Wiener  Med.  Halle,  1863,  Nos.  45,  46. 

2  Edinh.  Med.  and  Surg.  Journ.,  xviii.,  p.  393. 

3  Transactions  of  the  American  Otological  Societi/,  1870. 

4  Anatonde  Palliohgique  du  Corps  Humain,  ii.,  xxvi.,  planche  2. 


28 


PATHOLOGY  OF    THE  EAR. 


vestige  de  degeneration  cancereuse,"  From  a  remark  of  Cruveil- 
hier's,  it  seems  to  be  implied,  that  he  had  frequently  found  tumors 
originating  from  the  posterior  and  anterior  surfaces  of  the  petrous 
bone.  "  Ces  tumeurs  sont  tantot  fibreuses,  tantot  osteo-fibreuses : 
d'autres  fois,  elles   presentent  la  degeneration   cancereuse  dans  une 


Destruction  of  the  Petrous  Bone  by  a  Fibrous  Tumor,  from  Cruveilhier.  The 
tumor  originated  apparently  from  the  extension  of  the  dura  mater  into  the  porus 
acusticus  internus.  The  openings  in  the  bone  involve  the  inner  half  of  the  posterior 
surface  of  the  pars  petrosa.  communicate  extensively  with  the  eanalis  caroticus,  and 
unite  the  meatus  auditorius  internus,  which  cannot  be  recognized,  with  the  foramen 
lacerum  posterius. 

partie  de  leur  etendue.  La  description  des  tumeurs  du  rocher  me- 
riterait  de  trouver  place  dans  I'histoire  des  tumeurs  developpees 
dans  le  crane,"  etc.  Death  generall}'  results  from  marasmus  or 
pressure  on  the  brain,  sometimes  from  basilar  meningitis. 


AURICLE. 
Malformations. 

Foiyc'/,  Handbuch  der  Patholog.  Anatomie.  Halle.  1804.  —  MecM, 
Handbuch  der  Patholog.  Anatomie.  I.  S.  400-40G.  —  Beck,  Krankheiten 
des  Gehororgans.  Heidelberg  und  Leipzig:,  1827.  S.  106.  —  Mich.  Jdr/er, 
Klin.  Beobachtungen  iiber  Augen-  und  Oln-krankheiten  (Von  Amnion's 
Zeitscbrift  fUr  Opbth.  V.  1).  —  Hi/rtI,  Boitriige  zur  Patholog.  Anatomie 
des  Geliororgans.  Oesterr.  Med.  Jahrb.  XL  1838.  (On  Congenital  Mal- 
formations in  Deaf-mutes  and  Monstrosities.)  —  Von  Amman,  Die  Ange- 
borenen  Cbirurg.  Krankheiten  des  Menscben.  Berlin,  18.S9.  S.  26.  Taf. 
Y.    Fiir.    12-17.      Taf.   XXXHL    Fi^.    16.  —  5c/im«/c,  Verkummerung 


A  UPdCLE. 


29 


der  Ohrmuschel  mit  Felilen  des  Gehorgangs.  Beitriige,  etc.,  Leipzig, 
184G.  S.  1  u.  2.  —  A.  Thompson,  Edinburgh  Journ.  of  Med.  Science,  April, 
1847.  —  Birnbaiun,  Diss.  Inaug.  Giessen,  1848. — Wallmann,  Ueber  Miss- 
bildungen  des  Knocbernen  Gehororgans.    Virch.  Arch.  1857.   YI.    S.  G03. 

—  StahL  Einige  Skizzen  iiber  Missstaltungen  des  ausseren  Ohres.  All- 
gem.  Zeitscbrift  fur  Psycliiatrie.  XVI.  S.  479.  l^bd.—  Toynbee,  D'ls- 
eases  of  the  Ear.  1860.  S.  15. — M.  Schultze,  Missbildungen  im  Bereiche 
des  ersten  Kiemenbogens.  Virch.  Arch,  XX.  S.  3  78. — Heusin(ier,\Jfthev 
Halskiemenfisteln  von  noeh  nicht  beobachteter  Form.  Virch.  Arch.  — 
iJete,  Ueber  Fistula  Auris  Congenita,  Meraorabilien.  VIII.  24  June,  18G3. 

—  Bauer,  Ueber  die  Fclsenbeine  der  Ilemicephalen.  Diss.  Inaug.  Mar- 
burg, 1863. —  Claudius,  Ueber  den  Schadel  der  Hemicephalen.  Zcitschr. 
f.  Rat.  jMed.  XXI.  2.  18G4.  —  Kollmann,  Beitriige  znr  Entwickelungsge- 
schiehte  des  Menschen.  Zeitschr.  fiir  Biologic.  IV.  S.  260  u.  Taf.  VII.  — 
Lucae,  Virch.  Arch.  XXIX.  S.  C2  and  A.  f.  O.  X.  S.  23S.  —  Heusinger, 
Virch.  Arch.  XXIX.  S.  3G1.  —  VircJwtv,  Ibid.  XXX.  S.  221  and 
XXXII.  S.  518.  —  VoltoUnl,  M.  f.  O.  II.  No.  1.  1866.  Flechinger,  All- 
gem.  Wiener  Med.  Ztg.  1866.  Xo.  16.  — Wreden,  Petersb.  Med.  Zeitschr. 
XIII.  S.  204.  1867. —  Heusinfjcr,  Deutsche  Zeitschrift  fiir  Thiermedicin 
und  Vergleichende  Pathologic.  II.  1870.  —  6V!<fte'',  Lehrbuch.  1870.  S. 
276. —  Schmitz,  Ueber  Fistula  Auris  Congenita  und  andere  Missbildungen 
des  Ohres.  Diss.  Inaug.  1873.  Halle. 


Fig.  II.  Fig.  12. 

Bilateral  Cats-ears  with  stenosis  of  the  meatus  and  congenital  deafness.    Unilateral 
atrophy  of  the  face. 


Malformations.  Complete  absence  from  arrest  of  de- 
velopment may  be  fonnd  on  one  or  both  sides.  Ab- 
sence  of  certain  parts  (lobule,  helix,  antihelix,  car- 


30 


PATHOLOGY  OF   THE  EAR. 


tilage),  and  imperfect  development  of  the  auricle 
(microtia)  of  various  kinds  is  much  more  common. 
Sometimes  the  auricle  appears  pressed  together  from 


Fig.  13. 


Fig.  14. 


Fig.  15.  Fig.  16. 

Cats-ear  on  the  left  dislocated  downwards;  on  the  right  abnormal  hypertrophy  of 
the  auricle.     Unilateral  atrophy  of  the  face. 

Fig.  16.    Bilateral  Malformation  of  the  Auricle  with  atresia  of  the  meatus.    Deaf- 
mutism. 


above  downwards,  the  cats-ear  as  seen  in  the  old 
statues  of  Pan  (Figs.  11,  12,  13,  14,  15) ;  sometimes 
spindle-shaped  (Figs.  16,  17),  and  with  deep  indenta- 
tions, or  even  with   horizontal   fissures.     The  tragus 


AURICLE. 


31 


may  be  so  turned  inwards  as  to  close  the  meatus  ;  in 
Fig.  18  only  the  fissured  lobule  was  present,  below 
which  was  the  entrance  into  a  meatus  extremely  con- 


Fig.  17. 

Fig.  17.     Unilateral  Deformity  of  tiie  Auricle  with  Atresia  of  the  Meatus. 
Fig.  18.     Microtia  with  Stenosis  of  tlie  Meatus.     Only  a  fissured  lobule  remains. 
Unilateral  atropln'  of  the  face. 


tracted  and  directed  upwards,  the  end  of  this  meatus 
being  closed  as  in  the  normal  ear  by  the  membrana 
tympani.  Posteriorly  from  this  rudimentary  auricle 
the  dislocated  cartilage  could  be  felt  under  the  skin. 

The  lobule  is  frequently  adherent  to  the  skin ;  the 
upper  edge  of  the  auricle  is  rarely  so  attached. 

Usually  with  deformity  of  the  auricle,  such  as  is 
represented  in  Figures  19,  20,  21,  22,  further  malfor- 
mations exist  in  the  deeper  parts  of  the  ear,  atresia, 
stenosis  or  complete  absence  of  the  meatus,  or  even 
of  the  labyrinth.  Exceptionally  the  other  parts  of 
the  ear  may  be  normally  formed. 

Stenosis,  or  atresia  of  the  meatus  externus,  is  spe- 
cially frequent.  According  to  Virchow  ^  congenital 
anomalies  in  the  external  ear  and  its  neighborhood 
are  to  be  referred  to  early  disturbances  in  the  closure 

1   VircJww's  Arcliio,  Bd.  30,  S.  2 21,  and  Bd.  32,  S.  518. 


32 


PATHOLOGY  OF   THE   EAR. 


of  the  first  branchial  cleft,  and  are  often  associated 
with  fistuliB  of  the  other  branchial  clefts,  cleft  jD^late 
and  other  forms  of  arrest  of  development  in  the  facial 
bones,  as,  for  instance,  with  unilateral  atrophy  of  the 
face  (Figures  12,  13,  and  18).     Stahl  had  already  di- 


Fig.   19. 


Fi?    20 


Fig.  19.  Deformed  Auricle  with  Absence  of  the  Meatus.  The  cartilage  undevel- 
oped, onl}' seven  lines  long,  and  with  three  small  illddincd  dcijitJMons.  Lobulus 
as  large  as  that  of  the  health}'  ear.  Helix  scarcely  perceptible,  tragus,  antitragus, 
antihelix,  concha  and  fossa  navicularis  wanting.  (From  Michael  Yaeger  in  Von 
Amnion's  "  Zeitschr.  f.  Ophth.,"  Bd.  V.,  H.  I.) 

Fig.  20.  Deformitj'  of  the  Auricle  with  Atresia  of  the  Meatus.  The  ear  is  very 
small  ;  the  posterior  edge  of  the  helix  is  turned  forwards  (r/)  ;  only  slight  traces  of 
the  antihelix  (e)  and  its  fossa  ;  the  tragus  (/)  turned  backwards  and  felt  through  the 
skin  as  a  cartilaginous  point.  From  the  tragus  a  cartilaginous  half-ring  could  be 
felt  running  downwards  and  forwards  which,  according  to  Yaeger,  was  a  trace  of  the 
cartilaginous  meatus.  Opposite  the  tragus  was  a  point  of  the  antitragus  (f/)  and  be- 
hind this  two  blind  fossa.  The  cartilage  proper  is  wanting;  the  lobule  is  united 
with  the  skin  at  its  posterior  edge  and  lower  end ;  the  helix  the  same;  at  the  unat- 
tached spot  a  pouch-like  depression  two  lines  long  and  the  same  broad  existed. 
(From  Michael  Yaeger.) 

rected  attention  to  the  fact  that  deformity  of  the 
auricular  cartilag;e  mio-ht  be  reg-arded  as  an  indication 
of  imperfect  development  of  the  rest  of  the  skull,  and 
that  it  bore  a  semeiotic  relationship  to  the  develop- 
ment of  the  skull. 


A  URICLE. 


33 


Rudimentary  auricles  are  not  usually  inserted  in 
the  normal  position.  It  may,  however,  also  happen 
that  well-formed  auricles  are  dislocated  on  to  the 
cheek,  neck,  or  shoulder. 

A  by  no  means  rare  form  of  arrest  of  development 
is  the  fistula  auris  congenita,  first  described  by  Heu- 
singer,  which  is  to  be  regarded  as  a  remnant  of  the 
first  branchial  cleft.  The  fistulous  opening  generally 
lies  in  front  of  the  ear,  usually  one  centimeter  above 


Fig.   21. 


Congenital  Deformity  of  the  Auricle. 
(From  J.  Griiber,   "  Lehrbuch,"  S.  275.) 


Fig    22 

Microtia     (From  J.  Gruber,  "Lehr- 
bucli,"  S.  275.) 


the  tragus,  but  sometimes  it  is  in  the  lobule  (Betz). 
A  portion  of  the  fistulous  canal  can  sometimes  be  fol- 
lowed with  a  very  fine  probe  or  bristle,  or  its  callous 
walls  can  be  felt  between  the  auricular  cartilage  and 
the  skin.  From  its  opening  a  whitish  yellow,  cream- 
like fluid  exudes,  which  contains  numerous  pus  cells. 
By  closure  of  the  fistula  small  tumors  produced  by 
the  retention  of  the  secretion  may  form  in  front  of 
the  tragus.  On  the  same  spot  in  the  skin  in  front 
of  the  meatus  very  small  cicatricial  depressions  are 


34 


PATHOLOGY  OF   THE  EAR. 


often  seen  which  are  also  to  he  referred  to  anomahes 
m  the  closure  of  the  first  branchial  cleft.  These  fis- 
tulse  exist  with  or  without  malformation  of  the  auri- 
cle ;  sometimes  they  are  associated  with  fistulas  of 
the  neck.  Communication  with  the  middle  ear  or 
pharynx  could  not  be  found  in  the  cases  which  I  have 
observed. 


Excessive  development 


seen  as  (1)  abnormal  en- 
largement, complete  or 
partial  (Figures  13  and 
15,  right  ear) ;  (2)  auricu- 
lar appendages  (polyotia) 
which  may  be  said  to  du- 
plicate certain  parts  of  the 
auricular  cartilage.  Un- 
der the  skin  a  misplaced 
bit  of  cartilage  can  be  felt. 
These  appendages,  accord- 
ing to  Virchow,  consist  of 
skin,  subcutaneous  cellu- 
lar tissue,  and  reticular 
cartilage  ;  they  are  seldom 
numerous,  are  most  com- 
mon in  front  of  the  tragus, 
but  may  be  situated  on  the 
lobule  or  side  of  the  neck. 
(3)  Reduplication.  Lan- 
ger  found  four  lobules  in 
two  cases  of  monstrosities  with  double  bodies.^  Wilde 
describes  a  case  from  Cassebohm  of  a  child  with  two 
ears  in  the  usual  situation  and  two  below  on  the 
neck. 

1  L  c. 


Fig.  23. 

Auricular  Appendages,  Polyotia  ;  three 

wart-like  appendages  in  front  of  ♦he  ear. 

(From  Von  Amnion,  Table  xxxiii.  Fig. 

16.) 


AURICLE.  3t) 

The  form,  size,  position,  and  angle  of  insertion  of 
the  auricle  is  subject  to  very  great  individual  varia- 
tions. Irregularities  in  the  formation  of  the  helix  are 
very  common.  Darwin  assigns  a  so-called  pointed 
ear,  i.  e.,  an  ear  with  a  sharply  defined  indentation  of 
the  helix,  as  is  constantly  seen  in  old  statues  of  satyrs 
and  centaurs,  to  the  earliest  orders  of  human  beings. 

Othsematoma  (blood-tumor,  haematoma  auriculgB,  pe- 
richondritis auricularis,  erysipelas  auriculie.^) 

Bird,  Journ.  v.  Grafe  und  Walther.  1833.  XIX.  S.  631.  — Saxe,  De 
Othfematomate  Yesanorum  Commentatio.  Diss.  Inaug.  Leipzig,  1853, 
witli  tlie  literature  up  to  1852.  —  R.  Hofmann,  Oesterr.  Zeitschr.  fiir 
pract.  Heilkunde.  1862.  No.  33. —  G.  i/rtase  (Henle's  und  Pfeuifer's 
Zeitscbr.  III.  Reilie.  Bd.  24.  S.  82.  1865).  A  complete  catalogue  of 
the  literature,  1833-1864. —  Virchow,  Gescliwlilste.  1.  S.  135.  — Z.  Meyer, 
Vircliow's  ArcMv.  XXXVII.  Heft  4.  —  Gudden  (Zeitsclar.  fiir  Psychia- 
trie.  XVIIL).  —  Grlednger.  —  Parreidt,  Diss.  Inaug.  1864.  Halle.  — 
Haupt,  Diss.  Inaug.  1867.  WUrzburg. 

This  is  a  fluctuating  tumor  on  the  concavity  of  the 
auricle  formed  by  a  discharge  of  blood  between  the 
perichondrium  and  cartilage.  The  perichondrium  is 
not  only  separated  by  the  effusion  from  the  cartilage, 
but  bits  of  the  cartilage  usually  remain  attached  to 
the  membrane.  In  fresh  cases  it  comes  on  with  in- 
flammatory symptoms,  most  frequently  during  de- 
mentia paralytica,  but  it  may  occur  in  persons  of 
sound  mind ;  it  is  by  no  means  always  of  a  traumatic 
nature.  A  predisposition  to  it  is  shown  by  a  disease 
of  the  cartilage  which  shows  spots  of  softening  and 
spaces  filled  with  fluid. 

The  hemorrhage  is  generally  resorbed  and  the 
thickened  perichondrium  is  again  attached  to  the 
cartilage,  but  a  permanent  deformity  is  left  from  the 

^  Compare  Kleb's  Pathologiscke  Anatomic,  Bd.  I.,  S.  98, 


36 


PATHOLOGY  OF   THE  EAR. 


thickening  and  cicatricial  shrinking  of  the  auricle. 
Suppuration  and  spontaneous  rupture  are  very  rare 
and  only  occur  in  traumatic  othasmatoma.  Calcifica- 
tion of  the  cartilage  is  common  as  a  result  of  the  ef- 
fusion. 

Inflammations  and  their  Results.  The  usual  diseases 
of  the  skin  may  be  located  on  the  auricle.  Erythema 
(as  intertrigo  behind  the  ears),  eczema,  erysipelas,  are 
very  common,  phlegmonous  inflammation,  gangrene 


Fig.  24. 
Nrevus  of  the  Auricle.     Removed  with   the    knife  bj'  Prof.  R.   Yolkman,  .after 
the  application  of  a  ligature.     Recovery. 

(in  typhus,  measles,  erysipelas,  or  spontaneously  in 
nurslings),  are  less  common.  Lupus,  pemphigus  syph- 
iliticus, and  ichthyosis  congenita,  are  also  seen  on  the 
auricle.  Spontaneous  perichondritis  resulting  in  ab- 
scess, has  been  in  rare  cases  observed  on  the  auricle 
and  heals  usually  without  leaving  a  deformity.  Par- 
tial calcifications  and  very   rarely  ossifications,^  the 


1  Bochdalek,  Prag.  VierteljahrsscJir.,  1865,  i.,  S.  33. 
trdge. 


Otolofjisclie  Bei- 


A  URICLE. 


37 


result  of  defective  nutrition  alone  without  a  sign  of 
appreciable  irritation,  may  be  seen  on  the  auricle  ; 
concretions  of  urate  of  soda  are  also  found  in  ar- 
thritic persons  (Garrod).  The  auricle  is  almost  com- 
pletely exempt  from  syphilis,  and  fractures  are  very 
rare  on  account  of  its  elasticity.  After  burns  and 
skin  eruptions  synechiaB,  or  adhesions  of  the  auricle 
at  its  posterior  surface  to  the  skull,  may  occur. 

New  Growths. 


de    Cancro    Auris    Humanfe 
Mitteldorpf,    Galvanocaustik. 


1804. 
111.  — 


Fischer ,  Comment, 
Habilitationsschrift.  - 
Wilde,  Practical  Obsei'vations, 
etc.  1855.]).  193.  —  Von  Bruns, 
Handbucli  der  Pract.  Cliirurg. 
1859.  Abth.  II.  S.  135,  Abth.  II. 
S.  IG7.— A.  Wagner,  Konigsh. 
Med.  Jahrb.  1859,  IT.  S.  115.— 
Berend,  Deutsche  Klinik.  1864. 
S.  483.  —  Velpeau,  Cancroid  of 
the  Auricular  Cartilage.  Gaz. 
des  Hop.  18G4.  No.  27.  —  0. 
Saint-  Vel,  Ueber  Fibrome.  Gaz. 
des  Hop.  1864.  No.  84.  — F/r- 
chow,  Geschwiilste.  III.  S.  347. 
1867.  (Auriculare  Angiome.)  — 
J'ungken,  Berl.  Klin.  Wochen- 
schrift.  1869.  No.  8.  (Gefass- 
geschwiilste.)  Knapp,  Fibrome 
des  Lobulus.  (A.  f.  A.  u.  O. 
V.   1.     S.  215.) 


New  Growths.    Tumors 
produced  by  the  collec- 
tion and  retention  of  the  Am  icie 
sebaceous   secretion   of 
the  skin  (atheromata),  are  very  frequent,  possibly  be- 
cause there  are  no  smooth  muscular  fibres  on   the 


Fig.  25. 
\tliei-oma  on  the  Posterior  Surface  of  the 
natural    size.      (From    J.    Gruber, 
Lehrbuch,"  S.  407.) 


38  PATHOLOGY  OF   THE  EAR. 

auricle,  through  the  contraction  of  which  the  expul- 
sion of  the  sebaceous  matter  is  produced.-^  Fibroids 
(cicatricial  keloid)  are  often  developed  on  the  lobule 
as  the  result  of  piercing  the  ear,  and  may  grow  to 
the  size  of  a  hen's  Qgg  ;  the}^  are  most  common  in 
negresses.  Histologically,  they  show  the  exact  struc- 
ture of  cicatrices  in  the  skin,  and  frequently  recur 
when  imperfectly  removed.  Angioma,-  lipoma,  cav- 
ernous tumors,  epithelial  and  chimney-sweeper's  can- 
cer,^ and  cysts  are  also  found.  What  Wilde*  describes 
and  figures  as  a  cyst,  is  probably  a  ha3matoma. 

Epithelial  cancer  of  the  auricle  is  not  unfrequent, 
and  may  by  extension  lead  to  destruction  of  the  mid- 
dle and  inner  ears. 

THE    EXTERNAL    MEATUS. 

Malformations.  Complete  absence  of  the  meatus  is 
found  with  a  simultaneous  absence  or  deformity  of 
the  auricle,  and  also  with  congenital  absence  of  the 
membrana  tympani  (Michael  Jaeger).  In  place  of  the 
meatus,  a  compact  wall  of  bone,  several  lines  thick,  is 
then  found.  Sometimes  at  the  seat  of  the  entrance 
to  the  meatus,  only  slight,  single,  double,  or  multiple 
depressions  exist,  or  the   cartilaginous   meatus   may 

1  Dr.  Sappey,   Gazette  de  Paris,  1863,  24. 

2  Examples  of  congenital  angioma  of  the  auricle  are  given  Ijy  Jling- 
ken  (Berliner  Klin.  Wochenschrift,  1869,  No.  8).  They  grew  in  the 
meatus  and  in  the  depression  between  the  mastoid  process  and  the  con- 
dyloid process  of  the  lower  jaw.  Jiingken  ligated  the  common  carotid 
artery,  as,  from  a  rupture  of  the  tumor,  a  nearly  fatal  hemorrliage  oc- 
curred. Seven  years  after  the  operation,  there  occurred  a  fresh  hemor- 
rhage from  the  tumor,  and  death. 

3  Have  been  frequently  described  on  the  ear  by  English  surgeons. 

4  Practical  Observations,  p.  201. 


THE  EXTERNAL  MEATUS.  39 

be  present,  and  at  the  bottom  of  it,  instead  of  the 
osseous  meatus,  there  may  be  a  membranous  ^  or  firm 
osseous  closure  (atresia  congenita).  If  the  deej^er 
parts  of  the  ear  are  well  formed,  this  condition  is  not 
inconsistent  with  fair  hearing,  as  has  been  shown 
by  old  observations."^ 

Sometimes  the  funnel-shaped  end  of  the  narrow 
cartilaginous  portion  passes  into  a  very  fine  canal, 
which  extends  farther  inwards.  In  other  cases  the 
meatus  is  narrowed  equally  throughout  its  extent, 
or  it  may  be  contracted  like  an  hour-glass  near  its 
middle,  or  it  may  show  a  contraction  close  to  the 
membrana  tympani  produced  by  an  abnormal  projec- 
tion of  the  anterior  osseous  wall.  According  to 
Moos'^  band-like  bridges  of  connective  tissue  be- 
tween the  walls  of  the  meatus  may  occur  as  con- 
genital malformations.  The  existence  of  congenital, 
abnormal  width  of  the  meatus,  which  may  be  so  pro- 
nounced that  the  little  finger  can  be  inserted  down  to 
the  drum-membrane,  is  of  little  pathological  interest. 

Some  instances  of  a  double  meatus  are  known, 
which  are  undoubtedly  to  be  referred  to  arrest  in  the 
closure  of  the  first  branchial  cleft.*  In  one  case  by 
Velpeau,  one  meatus  led  to  the  drum-membrane, 
while  the  second  ended  in  the  mastoid  process ;  in 
one  case  by  Bernard,  the  two  passages  communicated 

^  This  also  occurs  near  the  drum-membrane.  Toynbee,  London  Med. 
Gazette,  1850,  p.  645. 

2  Mussey  in  New  York,  1838,  American  Journal.  Schnidt's  Jahrhueh. 
1839,  S.  320. 

3  Klinik  der  OhrenJcrankheiten,  S.  85. 

*  Voigtel,  i.,  S.  295.  Loder,  i.,  S.  148,  No.  583.  Bernard,  Journal  de 
PJiysiologle  Experbnentale  de  Magendie,  iv.  Blandin.  Lincke,  Handbuch, 
i.,  S.  623. 


40  PATHOLOGY  OF   THE  EAR. 

and  were  covered  with  a  continuation  of  the  external 
skin. 

In  childhood,  and  up  to  the  fourth  year  (accord- 
ing to  Huschke),  an  ossification  gap,  closed  merely 
by  connective  tissue,  is  found  normally  in  the  anterior 
lower  wall,  to  which  Yon  Troeltsch  first  directed  at- 
tention. The  knowledge  of  this  fact  is  of  importance, 
to  avoid  mistaking  it  for  a  carious  opening.  In  adults, 
remains  of  this  opening  are  occasionally  met  with  in 
exceptional  cases.  During  purulent  inflammations  of 
the  middle  ear,  ulcerative  destruction  of  the  skin 
over  this  spot  of  deficient  ossification  may  occur,  and 
through  the  opening  an  extension  of  the  inflannna- 
tory  process  of  the  meatus  may  reach  the  parotid 
gland  and  the  lower  jaw. 

Hypersemia  and  Hemorrhage.  Hyper^emia  of  the  skin 
of  the  meatus,  with  or  without  swelling,  is  seen 
in  the  beginning  of  a  diffuse  otitis  externa ;  in  the 
deeper  parts  of  the  osseous  meatus  during  acute  in- 
flammations of  the  tympanum  and  on  the  posterior 
upper  wall  during  inflammations  of  the  mastoid  pro- 
cess ;  venous  hypersemia  is  also  found  wdth  disease  of 
the  heart  and  emphysema  of  the  lungs. 

Hemorrhages,  aside  from  those  of  traumatic  origin, 
Avhich  are  the  result  of  direct  or  indirect  injuries, 
(fractures  of  the  lower  jaw,  bruises,  etc.),  ma}^  occur 
in  the  skin  of  the  meatus,  in  the  form  of  ecchymoses 
and  blood-blisters,  i.  e.,  hemorrhages  between  the  ep- 
idermis and  cutis,  accompan3'ing  inflammations  of  the 
middle  ear.  They  are  usually  situated  on  the  upper 
wall  of  the  meatus,  and  may  extend  directly  into  the 
membrana  tympani.  In  the  severer  forms  of  otitis 
media  purulenta,  before  rupture  of  the   drum-mem- 


THE   EXTERNAL  MEATUS.  41 

brane  has  taken  place,  I  have  frequently  seen  an 
extensive  vesicular  separation  of  the  epidermis  on  the 
upper  wall  of  the  meatus  produced  by  a  sero-hemor- 
rhagic  exudation. 

Inflammations  and  their  Results.  In  addition  to  the  dif- 
ferent varieties  of  inflammation  of  the  skin  (ery- 
thema, eczema,  herpes,  pemphigus,  erysipelas)  the 
external  portion  of  the  meatus  is  subject  to  furuncles 
and  phlegmonous  inflammation ;  the  inner  portion  of 
the  osseous  meatus,  where  the  cutis  is  very  thin  and 
cannot  be  separated  anatomically  from  the  perios- 
teum, i.  e.,  where  the  soft  tissues  consist  merely  of  a 
periosteum  covered  with  epidermis,  is  subject  to  j^eri- 
ostltls.  In  the  acute  exanthemata,  also,  the  skin  of 
the  meatus  is  not  always  spared  ;  it  is  w^ell  known 
that  the  ^9?«s/?«/es  of  small-pox  may  show  themselves 
not  only  on  the  auricle,  but  also  in  the  cartilaghious 
portion  of  the  osseous  meatus. 

In  rare  cases  diffuse  hypertrophy  of  the  epidermis 
of  the  papillary  bodies  {ichthyosis),  leads  to  narrow- 
ing and  distortion  of  the  canal,  and  to  diffuse  hyper- 
trophies of  the  skin  and  the  subcutaneous  cellular 
tissue  (pachydermatitis) . 

The  common  name,  "  catarrh  of  the  external  mea- 
tus," formerly  much  abused,  has  anatomically  no  jus- 
tification, except,  perhaps,  in  those  cases  in  which  the 
epidermis  has  been  destroyed,  as,  for  instance,  in 
acute,  moist  eczema  ;  it  was  used,  however,  as  a  gen- 
eral designation  of  the  various  forms  of  inflammation 
of  the  skin,  which  lead  to  suppuration,  and  which,  in 
their  later  stages,  cannot,  either  during  life  or  after 
death,  be  sharply  defined  one  from  another.  For 
these  different  processes,  the  name  otitis  externa  must 


42  PATHOLOGY  OF  THE   EAR. 

be  used,  but  it  must  be  distinctly  understood  that 
such  an  otitis  purulenta  externa  (in  which  the  whole 
surface  of  the  meatus  and  drum-membrane  is  the  seat 
and  source  of  the  otorrhoea)  is  to  be  regarded  as  the 
primary  source  of  profuse  suppurations  only  in  very 
few  cases  (most  commonly  in  childhood,  and  with  sup- 
purative parotitis  in  typhus).  In  the  great  majority 
of  cases  the  source  of  the  suppuration  is  in  the  mid- 
dle ear,  and  the  pus  only  flows  into  the  meatus 
through  an  opening  in  the  drum-membrane.  The 
otitis  externa  purulenta  without  perforation  of  the 
drum-memlirane  which  is  met  with  in  adults,  is  usu- 
ally only  an  accompanying  symptom,  or  the  precursor 
of  acute  inflammation  of  the  drum-cavity  (sympa- 
thetic inflammation,  Toynbee). 

The  otitis  externa  chronica  due  to  fungous  growths, 
otomycosis,  perhaps  the  most  common  form  which  is 
found  in  adults/  is  characterized  by  a  slight  and 
chiefly  serous  secretion  and  a  collection  of  macerated 
epidermis  cells  between  which  the  fungus  grows. 
With  profuse  suppuration  the  fungus  does  not  meet 
with  a  favorable  resting-place. 

Erythema  (erythematous  dermatitis)  is  a  hyperse- 
mia  and  serous  infiltration  of  the  papillary  bodies. 
The  secretion  of  the  glands  is  at  first  diminished,  or 
checked  entirely.  After  the  erythema  the  epidermis 
scales  off,  and  a  profuse  hypersecretion  of  a  thin, 
bright  yellow  cerumen  may  follow. 

Eczema  (acute  or  chronic)  is  often  confined  to  the 
external  ear.  The  vesicles  may  be  visible  on  the 
meatus  and  membrana  tynipani ;  in  most  cases,  how- 
ever, only  a  red  and  moist  skin,  from  which  the  epi- 

1   Vide  p.  56. 


THE  EXTERNAL  MEATUS.  43 

dermis  has  been  separated,  is  seen.  According  as  pus- 
tules or  dry  scales  are  formed  with  the  vesicles  the 
disease  is  called  eczema  impetiginosum  or  squamosum. 
In  obstinate  cases  chronic  eczema  of  the  ear  may  cause 
inflammatory  hypertrophy  of  the  corium,  which  can 
produce  stenosis  of  the  meatus,  deformity  of  the  auri- 
cle, and  thickening  of  the  cutis  of  the  drum-membrane. 

A  not  infrequent  complication  of  eczema  of  the 
meatus  is  mucous  catarrh  of  the  middle  ear,  without 
perforation  of  the  membrana  tympani. 

Furuncle,  or  perifollicular  inflammation  in  the  skin 
of  the  meatus,  offers  no  special  peculiarities.  In  ac- 
cordance with  the  anatomy  of  the  parts  it  occurs  only 
in  the  external  third  of  the  canal,  and  according  to 
some  authors  (Verneuil,  Roser)  develops  around  the 
ceruminous  glands.  The  most  common  seat  of  the 
furuncle  is  the  anterior  lower  wall  of  the  meatus. 

Usually  several  follow,  one  after  the  other,  and,  in 
some  individuals,  obstinately  recur  for  many  years. 
Large  furuncles  may  produce  a  temporary  closure  of 
the  meatus,  so  that,  if  the  skin  is  thick  and  without 
redness,  they  give  the  impression  at  first  view  that 
union  of  the  walls  of  the  meatus  has  taken  place.  As 
their  results  a  slit-like  narrowing  of  the  meatus  and 
free  desquamation  of  the  epidermis  may  remain  for 
some  time,  by  which  the  passage  may  be  closed. 
Granulations,  growing  on  the  edges  of  the  ruptures 
through  which  evacuation  has  taken  place,  may  sim- 
ulate a  pol3q3us. 

The  diffuse  inflcmimation  of  the  skin  is  preceded  by 
hypera3mia  and  swelling,  most  marked  in  the  vicinity 
of  the  drum-membrane  and  in  the  meml^rane*  itself; 
it  causes  destruction  and  loss  of  the  epidermis  and  su- 


44  PATHOLOGY  OF   THE   EAR. 

perficial  suppuration.  The  fluid  elements  of  the  puru- 
lent secretion  consist  in  part  of  a  transudation  from 
the  greatly  enlarged  blood-vessels,  in  part  originate  in 
the  perspiratory  and  sebaceous  glands.  If  the  blood- 
vessels are  ruptured  the  pus  will  be  temporarily 
bloody.  The  inflammation  can  extend  from  the  ele- 
ments of  the  cutis  and  involve  the  subcutaneous  cel- 
lular tissue,  producing  there  a  new  formation  of  round 
cells  (phlegmonous  inflammation).  If  not  relieved  by 
early  and  deep  incisions  the  inflammation  may  go  on 
to  gangrene,  extensive  destruction,  disease  of  the 
bone,  or  even  to  purulent  thrombosis  of  the  sinuses 
and  septica3mia.  Also  in  periostitis  of  the  meatus 
death  may  result  in  exceptional  cases  from  purulent 
thrombus  of  the  sinuses  or  meningitis  (Toynbee),  with- 
out disease  of  the  tynqmnitm  and  icithout  'perforation 
of  the  me^nbrana  tymj^ani} 

As  other  residts  of  inflammation  of  the  meatus 
should  be  mentioned  ;  strictures,  sometimes  caused 
merely  by  a  thickening  of  the  cutis,  sometimes  by 
simultaneous  hyperostosis.  In  the  cartilaginous  por- 
tion, especially  at  the  point  where  the  cartilaginous 
joins  the  osseous  meatus,  annular  strictures  may  be 
formed  by  a  cicatricial  circular  thickening  of  the  con- 
nective tissue.  Behind  the  stricture  the  osseous  mea- 
tus may  be  very  much  enlarged.  Such  strictures  are 
very  dangerous  complications  of  suppurations  of  the 

1  The  existence  of  a  primary  perichondritis  has  not  been  proven  ana- 
tomically. From  observations  during  life  there  is  a  certain  probability 
that  such  occurs  in  some  of  the  tedious  inflammations  where  the  swelling 
is  confined  to  the  external  half  of  the  meatus  and  produces  deep  sinuous 
abscesses  and  forms  fistulas  under  the  skin  of  the  meatus;  however, 
neither  from  my  own  observation  nor  from  the  literature  is  any  case 
known  to  me  where  a  necrosed  cartilajre  was  thrown  off. 


THE   EXTERNAL   MEATUS.  45 

middle  ear.  Adhesion  of  the  walls  of  the  meatus, 
noticed  by  Emmert  ^  with  a  simultaneous  union  of  the 
tragus  with  the  antitragus,  results  from  burns,  from 
diphtheria  of  the  middle  ear  (my  own  observation) 
in  connection  with  cicatricial  adhesions  of  the  palate, 
and  frequently  in  cases  in  which  there  is  caries  of  the 
middle  ear.  The  meatus  is  closed  either  by  a  mem- 
branous diaphragm  which  has  one  or  more  fine  open- 
ings in  its  centre,  or  else  the  osseous  portion  of  the 
meatus  is  completely  filled  by  a  new  fibrous  tissue 
(my  own  observation). 

A  neiD  growth  of  slight  hands  ^  uniting  the  walls  of 
the  meatus  with  each  other  is  sometimes  found,  but 
much  more  frequent  are  granulations  (polypoid  ex- 
crescences) from  the  cutis,  which  sometimes  completely 
fill  the  inner  portion  of  the  meatus,  and  may  give  the 
surface  of  the  membrana  tympani  the  appearance  of 
a  granulating  wound.  Thickening  of  the  cutis,  opac- 
ity or  perforation  of  the  drum-membrane,  is  also 
found. 

FistidcG  in  the  neighborhood  of  the  meatus,  and  fis- 
tulous perforation  of  its  walls,  are  usually  the  result 
of  caries  and  necrosis  (often  of  abscesses  of  the  mid- 
dle ear  which  break  through  the  posterior  upper  wall 
of  the  meatus,  and  which  are  frequently  mistaken  for 
primary  abscesses  and  furuncles  of  that  passage);  such 
fistula3  may,  however,  result  from  suppuration  of  the 
parotid  ^  and  the  neighboring  lymph  glands  without  an 
affection  of  the  bone,  and  may  also  result  from  cancer. 
Abscesses  of  the  parotid  usually  rupture  at  the  junc- 

1  CMrurgie,  III.  Auflage,  S.  173. 

2  A./,  d,  ix.,  237. 

3  Virchow,  Charite- Annalen,  1858,  viii.,  3.  C.  E.  E.  Hofinann,  A.f. 
0.,  iv.,  S.  283. 


46  PATHOLOGY  OF   THE  EAR. 

tion  of  the  cartilaginous  with  the  osseous  meatus  or 
else  through  the  incisurse  Santorini.  Vice  versa  in 
childhood  a  suppuration  of  the  meatus  may  extend  to 
the  parotid  gland  and  articulation  of  the  jaw  through 
the  ossification  gaps  already  described  (p.  40).  Fis- 
tulae  under  the  skin  of  the  cartilaginous  meatus  occur 
from  affections  of  the  bone,  from  phlegmonous  ab- 
scesses in  front  of  the  tragus,  and  possibly,  although 
this  is  doubtful,  from  perichondritis.^ 

Ulceration  is  rare.  Simple  erosion-ulcers  at  the  en- 
trance of  the  meatus  may  occur  from  inflammations, 
attended  by  profuse  and  putrid  suppuration  ;  ulcers 
are  also  sometimes  found  with  caries  and  necrosis, 
with  syphilis,  and  with  epithelial  cancer.  Von 
Troeltsch^  found  an  ulcer  with  sharply  projecting 
edges  extending  down  to  the  bone  on  the  posterior 
wall,  close  to  the  membrana  tympani,  in  a  case  of 
miliary  tubercular  meningitis  with  simultaneous  sup- 
puration of  the  middle  ear.  The  ulcers  found  with 
constitutional  syphilis  are  annular  and  covered  with 
a  dirty  grayish  white  exudation ;  from  their  edges 
being  greatly  swollen  they  cause  contraction  of  the 
meatus,  and  when  they  exist  the  lymph  glands  in  the 
vicinity  of  the  ear  are  much  swollen. 

The  skin  of  the  meatus,  if  it  has  lost  its  epidermis 
from  moist  eczema,  or  from  any  other  cause,  may,  like 
the  skin  of  the  auricle  when  affected  by  intertrigo, 
assume  the  character  of  a  diphtheritic  ulcer,  and  this 
has  been  called  by  Wreden  ^  and  by  Moos  ^  an  inde- 
pendent, primary  diphtheritis  of  the  skin  of  the  mea- 
tus.    This  dij)htheritic  ulceration  of  the  meatus  may 

1  Vide  p.  45,  remarks.  ^  M.f.  0.,  1868,  No.  10,  S.  154. 

2  A.f.  0.,  iv.,  130.  4  Moos,  A./.  0.,  vi.,  S.  162. 


THE  EXTERNAL  MEATUS.  47 

lead  to  cicatricial  adhesion  of  the  walls  of  the  pas- 
sage.^ 

Collapse  of  the  meatus  means  a  slit-lilve  contraction 
of  the  passage  in  its  cartihiginous  portion,  seen  par- 
ticularly in  old  age,  and  often  produced  (Von 
Troeltsch)  by  a  relaxation  of  the  fibrous  attachments 
of  the  membranous  posterior  and  upper  portion  of 
the  meatus  to  the  squama.  From  this  relaxation  the 
posterior  wall  of  the  cartilaginous  meatus  falls  against 
the  anterior  wall. 

Hyperostosis  with  narrowing  of  the  meatus  is  most 
commonly  found  with  caries  of  the  middle  and  inner 
ear,  and  is  a  cause  of  retention  of  pus  ;  it  is  found, 
moreover,  with  non-purulent  chronic  inflammations  of 
the  middle  ear,  associated  with  a  growth  of  connective 
tissue  around  the  ossiculic,  and  also  frequently  exists 
with  osteo-sclerosis  in  the  mastoid  process  and  roof 
of  the  tympanum.  According  to  J.  Gruber,^  not  only 
a  thickening  of  the  osseous  portion  of  the  meatus  takes 
place,  but  the  ossification  extends  outwards  along  the 
cartilaginous  meatus  so  that  the  new  growth  of  bone 
may  reach  nearly  to  the  orificium  externum. 

Caries  and  Necrosis.  The  spot  of  preference  for 
caries  of  the  meatus  is  the  posterior 
upper  wall  near  the  membrana  tym- 
pani,  corresponding  either  to  the 
floor  of  the  antrum  mastoideum,  or 
to  the  point  where  the  antrum  en- 
ters the  tympanum.  Preceding  the 
rupture  of  the  cutis  the  skin  of  the  ^'^s-  26. 

meatus  on  its  upper  and   posterior 
wall    appears    thickened    and    infil-  of  the  upper  waii  of  the 
trated  with  pus ;  later  granulations 

'^   Vide  p.  45.  2  £ehrbuch  der  Ohrenheilkunde,  S.  387. 


The  Head  of  the  Har 
mer  exposed  from  caries 


48  PATHOLOGY  OF   THE   EAR. 

are  seen  projecting  from  the  carious  opening,  or  the 
opening  itself  can  be  seen  surrounded  by  extruding 
edges  of  skin.  If  the  carious  destruction  attacks  the 
upper  wall  of  the  passage  near  the  drum-membrane, 
the  head  of  the  hammer,  either  in  articulation  with 
the  body  of  the  incus  or  separated,  will  be  fully  ex- 
posed and  can  be  readily  seen  on  inspection.  If  both 
of  these  ossicles  have  been  lost  the  corresponding  por- 
tion of  the  tympanum  is  exposed. 

Partial  necrosis  of  the  osseous  meatus  with  the  loss 
of  large  portions  of  its  walls  results  quite  frequently 
from  long  continued  suppurations,  especially  in  child- 
hood. The  OS  tympanicum  alone  may  also  be  at- 
tacked by  necrosis. 

Anomalies  of  Secretion  are  noticed  in  the  sebaceous 
and  perspiratory  glands  of  the  cartilaginous  meatus. 
The  meatus  of  the  new-born  child  contains  vernix 
caseosa,  which  completely  covers  the  membrana  tym- 
pani.  A  h}- persecretion  of  the  glands  (seborrhoea)  is 
very  common,^  and  forms,  from  long  retention  and 
thickening  of  the  secretion  due  to  the  loss  of  its  fluid 
elements,  obstructing  masses  which  may  by  mechan- 
ical irritation  cause  secondary  inflammatory  changes 
in  the  skin.  Whether  changes  in  the  glands  them- 
selves, such  as  hyperplasia  or  degeneration  of  the 
glandular  epithelium,  is  the  cause  of  the  frequent  re- 
currence of  such  masses,  remains  to  be  investigated. 

These  masses  only  produce  a  functional  disturb- 
ance when  they  hermetically  close  the  meatus  or  lie 
on  the  drum-membrane.     They  show  a  variable  ana- 

1  From  the  presence  of  foreign  bodies  the  inflammatory  irritation  of 
the  skin  very  rapidly  produces  hypersecretion  of  the  glands,  by  which  the 
foreio-n  body  may  be  in  a  few  hours  completely  embedded  and  covered. 


THE   EXTERXAL   MEATUS.  49 

tomical  composition.  Some  consist  almost  entirely 
of  the  secretion  of  the  sebaceous  and  •  sweat-glands, 
others  are  chieily  composed  of  masses  of  epidermis 
arranged  in  lamellae  (cul-de-sacs  of  epidermis  resem- 
bling the  finger  of  a  glove  and  filled  with  glandular 
secretion).  Hairs,  round  or  oval  bodies  resembling 
corpora  amylacea  but  not  giving  the  well-known 
reaction  to  iodine,  occasionally  an  acarus,^  and  mould- 
fungus,  are  also  found  in  these  masses.  Their  sur- 
faces are  sometimes  glistening  from  cholesterine. 
They  are  found  at  all  ages,  but  are  especially  common 
in  old  age. 

If  the  mass  completely  fills  the  meatus  down  to  the 
membrana  tympani,  wdiich  in  most  cases  is  not  the 
fact,  a  perfect  impression  of  the  drum-membrane  with 
all  its  characteristics  is  often  found  on  the  inner  end 
of  the  mass.  In  addition  to  secondary  inflammatory 
irritation  of  the  skin  these  masses  may  produce  atro- 
phy or  ulceration  of  the  membrana  tympani  from 
pressure,  but  still  more  commonly,  by  forcing  the 
drum-membrane  inwards,  they  favor  the  adhesion  of 
that  membrane  to  the  inner  wall  of  the  tympanum ; 
they  may  also  cause  a  circumscribed  atroph}^  of  the 
osseous  meatus,  and  thus  enormously  enlarge  that  pas- 
sage. Von  Troeltsch  ^  has  described  a  case  where  one 
of  these  masses  was  the  cause  of  a  fatal  facial  erysip- 
elas. On  the  other  hand  such  masses  are  not  uncom- 
monly complicated  by  other  and  wholly  independent 

1  First  found  by  Berger  in  cerumen  (Comptes  Rendus,  xx.,  S.  1506, 
1845);  previously  seen  by  Henle  in  the  sebaceous  glands  of  the  meatus 
(Miiller's  ArcMv,  1842,  S.  237). 

2  A.f.  C».,  vi.,  S.  48. 


50  PATHOLOGY  OF   THE  EAR. 

diseases  of  the  middle  ear,  for  instance,  synostosis  of 
the  stapes,  of  which  Morgagni  ^  gives  an  example. 

New  Growths.  Concretions  of  carbonate  and  phos- 
phate of  lime,  which  have  formed  in  the  ear,  have 
been  found  in  the  meatus ;  they  are  analogous  to  nasal 
concretions.  In  horses  similar  concretions  of  an  ivory 
consistency  frequently  exist. 

Encysted  tumor  has  been  seen  once  by  Pappen- 
heim.'^  It  was  attached  by  a  small  pedicle  to  the 
skin  and  closed  the  meatus ;  it  consisted  of  a  cavity 
formed  by  the  corium  and  epidermis,  and  was  filled 
with  a  white,  slightly  glistening  contents  consisting 
of  cholesterine,  epithelial  cells,  fat  globules,  and  crys- 
tals of  lime. 

The  tumors  described  by  Toynbee  under  the  name 
"  sebaceous  tumors  "  are  not  to  be  considered  as  en- 
cysted tumors  but  cholesteatomata. 

3IiUum  may  occur  in  the  meatus,  as  on  the  eyelid, 
in  the  form  of  a  white,  round  protuberance,  of  the 
size  of  a  millet-seed.  It  is  formed  from  an  obstructed 
sebaceous  gland. 

Pedunculated  warts  covered  with  a  normal  cutis 
containing  hairs  and  sebaceous  and  sweat  glands  are 
very  rare.  They  w^ere  found  by  Von  Troeltsch  ^  in 
two  cases  originating  from  the  upper  wall  ;  in  one 
case  the  growth  was  quite  near  the  drum-membrane. 

Polypi,  pedunculated  tumors,  may  have  their  ori- 
gin from  any  point  of  the  meatus,  usually,  however, 
they  grow  from  the  osseous  meatus  near  the  mem- 
brana  tympani,  and  should  not  be  confounded  with  the 

^  De  Sedibus  et  Causis  Morhorum,  lib.  i.,  ep.  xiv.,  art.  11. 

2  Spec.  Gewebelehre  des  Gelwrorgans,  1840. 

3  Lehrbuch,  6  Aufl.,  S.  504. 


THE   EXTERNAL  MEATUS. 


51 


granulation-growths  of  the  meatus  ah-eady  described 
on  p.  45.  In  one  case  described  by  Bihroth,  the  tu- 
mor originated  from  the  celkdar  tissue  between  the 
cartilage  and  the  skin.  In  regard  to  their  histolog- 
ical structure  it  should  be  said,  that  they  are  always 
covered  with  a  pavement  epithelium,  and  that  they 
contain  neither  glands  nor  cysts  like  the  polypi  of 
the  middle  ear,  although  like  these  latter  they  may 
have  a  papillary  structure.  Polypi  of  the  meatus  are 
much  more  rare  than  polypi  of  the  middle  ear,  but 
do  occur  with  an  imperforate  drum-membrane.  Some- 
times, however,  they  exist  simultaneously  with  puru- 
lent inflammation  of  the  middle  ear. 

For  a  more   minute  account  of  aural  polypi,  com- 
pare the  chapter  on  the  tympanum. 

Exostoses,^  congenital  or  acquired,  pedunculated  or 
w^ith  a  broad  base,  spongy  or  eburnated,  are  found. 
The  eburnated  may  be 
developed  from  the 
spongy  variety,  and  per- 
haps vice  versa.  Both 
are  only  diiferent  stages 
of  development  of  the 
same  process.  Their 
seat  is  generally  at  the 
beginning  of  the  osse- 
ous meatus  or  close  to 
the  membrana  tympani,  usually  on  the  upper  wall. 
The  calibre  of  the  meatus  may  be  almost  or  even 
wholly  destroyed  by  them,  but  as  long  as  a  slit  even 
remains  open  no  disturbance   of  the   hearing  is  no- 


Fig.  27. 
Exostoses  of  the  Meatus.    From  Welcker, 
A.  f.  O.,"  i.,  Table  2,  Fig.  7. 


^  C.  O.  Weber,  Die  Exostosen  und  Enchondromen,  Bonn,  1856.  Welcker, 
A.j:  0.,  l,  S.  163,  1864. 


52 


PATHOLOGY  OF   THE   EAR. 


ticed.  It  very  easily  occurs,  however,  under  such 
conditions,  that  the  glandular  secretion  and  the  scales 
of  epidermis  are  collected  and  retained  behind  or  be- 
tween the  exostoses,  and  thus  hermetically  close  the 
meatus.  From  the  pressure  of  the  exostoses  against 
the  opposite  wall,  painful  inflammation  of  the  meatus 


Fig.  28. 

Exostoses  on  the  Posterior  Wall  of  Jleatus 

near  the  drum-membrane. 


Fig.  29. 
Exostoses  of  the  Meatus. 


with  the  formation  of  granulations  may  take  place, 
and  from  the  retention  of  the  pus  may  lead  very  rap- 
idly to  perforation  of  the  drum-membrane  and  sup- 
puration of  the  tympanum. 

Exostoses  are  much  more  frequent  in  men  ;  are 
particularly  common,  according  to  Welcher,  in  the 
skulls  of  transmarine  races.  Toynbee  considered  rheu- 
matism and  arthritis  as  their  causes:  I  have  often 
seen  them  hereditary  and  unassociated  with  these 
diseases.  Syphilis  is  certainly  to  be  excluded  as  a 
cause.  With  chronic  suppurations  of  the  middle  ear 
exostoses  and  a  tendency  to  hyperostosis  often  form 
a  dangerous  complication,  as  they  especially  favor 
the  retention  of  the  pus. 

Epithelioma  of  the  meatus,  in  the  form  of  a  rough 
wart,  is  described  by  Kessel.^ 

Cholesteatomata  occurring  primarily  in  the  meatus 

1  A.f.  0.,  iv.,  S.  1S4. 


THE   EXTERNAL  MEATUS.  53 

are  described  in  large  numbers  by  Toynbee,^  as  seba- 
ceous tumors,  although  it  is  doubtful  if  he  is  not  re- 
ferring to  the  so-called  cholesteatomata  of  the  tympa- 
num or  antrum  mastoideum,-  which,  after  destruction 
of  the  membrana  tympani  or  of  the  posterior  wall  of 
the  meatus,  are  pressed  forward  into  the  meatus. 
Toynbee  certainly  ascribes  to  these  "  sebaceous  tu- 
mors," a  firm  enveloping  membrane  of  connective 
tissue,  which  has  its  origin  on  the  floor  of  the  meatus, 
near  the  drum-membrane,  (?)  and  he  considers  that 
the  meatus  may  be  considerably  enlarged  by  the  tu- 
mor, and  finally,  that  the  bone  may  be  perforated  by 
a  gradual  atrophy  produced  by  the  pressure  of  the 
mass.  According  to  him  the  membrana  tympani  may 
often  remain  intact  and  pressed  i^i  against  the  lab}^- 
rinthine  wall ;  in  other  cases,  however,  it  may  be  per- 
forated, and  through  the  opening  a  portion  of  the 
tumor  may  project  into  the  tympanum. 
•  Enchondroma  may  arise  from  the  cartilage  of  the 
meatus  and  simulate  a  parotid  tumor.'^ 

Cylindroma  is  a  name  given  by  H.  Meckel  von 
Hemsbach  to  a  form  of  tumor,  of  Avhich  he  has  de- 
scribed one  example.*  According  to  the  terminology 
of  the  present  day  it  would  perhaps  be  called  a  my- 
xoma cartilagineum. 

In  a  man  about  forty  years  of  age,  a  subcutaneous  tumor  gradu- 
ally developed  in  the  course  of  a  half  year  in  front  of  and  below 
the  external  meatus.  It  was  extirpated  by  Von  Barensprung.  The 
tumor  originated  from  the  cartilaghious  wall  of  the  meatus.  "Within 
the  passage  were  merely  small  flat  yellowish  nodules ;  on  the  outer 

^  Med.-Chirurg.   Transactions,  vol.  xliv.,  p.  51. 

2  Vide  p.  22. 

3  Launay,  Gaz.  des  Hup.,  1861,  46. 

^  Charite  Annalen,  Baud  vii.,  S.  105,  Fall  2. 


54  PATHOLOGY  OF   THE  EAR. 

surface  of  the  meatus,  however,  was  a  yellowish,  transparent  en- 
chonclromatous  mass  of  the  size  of  a  walnut,  consisting  of  numer- 
ous sharply  defiued  lobules.  Microscopically  it  showed  in  all  parts 
the  uniform  structure  of  a  pure  cylindroma. 

Injuries  of  the  meatus  from  sharp  substances  are 
very  common,  but  are  destitute  of  imjiortant  results 
if  the  membrana  tympani  and  the  parts  of  the  ear 
behind  it  are  untouched.  From  the  intentional  in- 
fusion of  melted  metals  and  mineral  acids  into  the 
ear,  and  the  thrusting  of  sharp  substances  as  far  as 
the  inner  ear,  severe  inflammations  with  a  fatal  result 
have  been  caused. 

From  the  action  of  force  on  the  under  jaw  (kick 
of  a  horse)  fractures  of  the  anterior  wall  of  the 
meatus  with  fracture  of  the  glenoid  cavity  but  without 
injury  of  the  deeper  parts,  and  especially  without  ex- 
tension of  the  fracture  to  the  base  of  the  skull,  and 
without  rupture  of  the  drum-membrane,  not  infre- 
quently occur. 

Fractures  of  the  base  of  the  skull  occasionally  ex- 
tend into  the  osseous  meatus,  and  may  even  break  off 
and  completely  separate  pieces  of  the  bone. 

Limited  fractures,  which  do  not  extend  to  the  base 
of  the  skull,  sometimes  occur  in  the  extremely  thin 
upper  wall  of  the  meatus  from  contusion  of  the  head. 
This  may  produce  injury  of  the  brain  and  evacuation 
of  brain  substance  from  the  ear,  without  death  neces- 
sarily resulting. 

Parasites. 

Animal :  Huber,  Yirchow's  Archiv.  Bd.  22.  Gerlach,  Allgcmeine 
Therapie  der  Hausthiere.  2  Aufl.  Berlin,  1868.  Zilrn,  Die  thierischen 
Parasiten  auf  und  in  dem  Kcirper  unserer  Hauss'augethiere.  1872.  Zilrn, 
Die  Ohrkrankheiten  der  Kaninchen.  Deutsche  Zeitschrift  fiir  Thier- 
mediein  uud  vergl.  Pathologie.    1  Bd.    1870.      Von   Trueltsch,  A.  f.   O. 


THE  EXTERNAL   MEATUS.  55 

IX.  S.  198.  1875.  Trautmann,  Protocoll  der  Section  fur  Ohrenh.  auf 
del-  Versammlung  Deutscher  Naturfoi'scher  und  Aerzte  zu  Hamburcr. 
1876.     A.  f.  O.  XI.  S.  272. 

Vegetable:  ^^alJer,  Miiller's  Arch.  f.  Anat.  u.  Phys.  1844.  S.  404. 
Pacini,  Gaz.  Mod.  Ital.  1851.  I.  Ser.  ]I.  Grove,  Quarterly  Journal.  1857. 
Vol.  V.  p.  IGl.  Cramer,  Vierteljahrsschrift  der  naturforsch.  Gesellsch. 
zu  Zurich.  1859,1860.  Scliwartze,  A.  L  O.  II.  S.  5.  18G5.  Wreden, 
A.f.  O.  in.  1,  1867.  TFre(/e/i,  Myringomycosis  Aspergillina.  Petersburg. 
18G8.  Sieudener,  A.f.  O.  V.  S.  163.  1870;  and  a  large  number  of 
later  observations. 

The  existence  of  animal  parasites  (acari,  gregari- 
ulae),  especially  dermanyssus  avium,  symbiotes,  derma- 
tophagus,  dermatodectes,  has  been  known  for  a  long 
time  to  the  veterinary  pathologists  as  a  common  oc- 
currence in  the  meatus  of  some  animals  (cow,  horse, 
dog,  cat,  rabbit,  goat),  where  they  may  cause  inflam- 
mations or  deep  necrosis,  even  into  the  labyrinth ; 
their  transmission  to  the  human  ear,  however,  with 
the  exception  of  acarus  folliculorum,^  has  not  yet  been 
observed,  although  from  the  close  relations  of  many 
persons  with  cats  and  rabbits  it  is  very  possible.^  On 
the  other  hand  vegetable  ixirasites  (aspergillus,  asco- 
phora  elegans,  trichothesium  roseum,  mucor  mucedo) 
are,  according  to  recent  observations,  much  more  com- 
mon than  was  formerly  supposed,  if  one  may  judge 
from  the  few  references  to  them  in  the  older  Avritinsrs. 

o 

The  attention  of  aural  surgeons  was  first  directed  to 
this  point  by  a  communication  of  the  author  in  1865 ; 
and  soon  communications  from  all  sides  and  from 
every  country  were  published,  so  that  the  fact  is 
now  fully  established  that  vegetable  parasites,  chiefly 
mould-fungi  (aspergillus  niger),  are    developed    and 

^  Compare  p.  49. 

2  Derniatodectes  in  the  ear  of  the  rabbit  was  first  observed  by  Gerlach; 
symbiotes  cati  in  the  ear  of  the  cat  by  Huber.  (Virchoic's  Archiv, 
Bd.  xxii.) 


56  PATHOLOGY  OF   THE  EAR. 

find  noiirisliment  in  the  human  meatus  auditorius 
and  produce  very  obstinate  and  recurring  inflamma- 
tions of  that  passage  and  of  the  drum-membrane 
(otomycosis  of  Virchow).  On  the  healthy  skin  of 
the  meatus  no  fungus  can  live  and  fructify ;  it  is  nec- 
essary for  the  development  of  the  growth  that  there 
should  exist  an  abnormal  condition,  possibly  loosen- 
ing of  the  epidermis,  or  a  superficial  inflammation  of 
the  skin.  In  my  opinion  we  have  to  deal  not  with  a 
parasitic  inflammation,  but  the  parasitic  growth  upon 
and  among  the  epidermal  cells  is  an  accidental  but 
important  accident  of  the  inflammation.  A  new  irri- 
tation is  added  by  the  fungus,  hypera^mia  and  exu- 
dation are  increased,  the  increase  in  the  vegetable 
growth  interferes  with  the  removal  of  the  secretion, 
and  of  the  loosened  layers  of  epidermis,  and  may 
finally  close  the  median  portion  of  the  meatus.  The 
surface  of  the  membrana  tympani  may  be  infiltrated 
with  the  fungus,^  and  if  there  is  a  perforation  of  that 
membrane,  the  tympanic  mucous  membrane  may  be 
afiected. 

The  diagnosis  of  otomycosis  can  frequently  be  made 
with  certainty  Avith  the  naked  eye.  The  fibres  of 
the  fungus  with  their  heads  of  fructification  in  insular 
groups  are  recognized  clearly  in  profile  against  the 
wall  of  the  meatus,  or  a  peculiar  white,  felt-like  de- 
posit is  seen  on  the  membrana  tympani.  In  many 
cases,  however,  the  diagnosis  is  doubtful  without  the 
use  of  the  microscope.  Most  frequently  the  otomy- 
cosis is  mistaken  for  a  chronic  eczema  squamosum. 

It  should  be  added  here  that  insects  (musca,  pulex, 

1  From  an  observation  of  Politzer's  it  is  established  that  the  fungus 
uiay  even  penetrate  the  tissue  of  the  drum-membrane. 


THE  DRUM-MEMBRANE.  57 

myriapodes)  and  their  larvas  may  get  into  the  meatus, 
and  where  destructive  processes  have  ah-eady  taken 
place,  may  reach  the  middle  and  inner  ears.  It 
should  also  be  mentioned  that  pus  in  the  meatus  often 
contains  numerous  bacteria  and  vibrios.  Leyden  ^ 
found  in  the  pus  of  a  carious  ear,  "  fine  spirals  of  from 
three  to  six  turns  which  sometimes  by  wave-like  mo- 
tion beat  the  surrounding  fluid  and  sometimes  con- 
tracted themselves  together."  They  belong  to  the 
lowest  vegetable  organisms  (schizomj'cetes). 

THE    DRUM-MEMBRANE. 

CasseboJnn,  Tractatus  IV.  Aiiatomici  de  Aure  Humana.  Halje,  1734. 
First  describes  the  deposits  of  lime  in  the  drnm-membrane.  Plainer, 
Diss,  de  Morbis  Membranse  Tympani.  Leipzig,  1780.  Gtudllsch,  De 
Morbis  Membranas  Tynip.  Dissertatio.  Leipzig,  1780.  Von  Troeltsch, 
Virch.  Arch.  XVIL  u.  f.  und  Lehrbuch.  Politzer,  Beleuchtungsbilder 
des  Trommelfells.  Wien,  18G5.  Politzer,  Zur  Patholog.  Anatomic  der 
Trommelfelltrubungcn.  Oesterr.  Zeitschr.  fiir  Prakt.  Heilk.  18G2.  VIII. 
4.3,  4G,  51.  Gniher,  Lehrbuch,  1870.  Wendt,  in  seinen  Anatomischen 
Beitriigen  in  Wagner's  Archiv  fiir  Heilkunde.  Hinton,  Atlas  of  the 
Membrana  Tympani  with  descriptive  text.     London,  1874. 

Pathological  changes  of  the  drum-membrane  are  extremely  com- 
mon, but  are  rarely  the  result  of  a  primary  aucl  isolated  disease  of 
that  membrane.  In  most  cases  they  are  to  be  regarded  as  the  sec- 
ondary results  of  diseases  of  the  middle  ear,  and  of  the  external 
meatus.  Dissection  alone  cannot  give  us  sufficient  information  in 
regard  to  the  changes  observed  during  life,  because  we  are  dealing 
with  an  organ  which  soon  after  death  changes  its  color,  polish, 
transparency,  and  curvature.  From  the  ease,  however,  with  which 
the  membrana  tympani  can  be  examined  during  life,  this  defect 
in  anatomical  investigation  can  be  readily  corrected. 

For   examining    the    histological    changes,  cross-sections  of   the 
membrane  are  best  adapted.     The  membrane  should  be    laid  for 
some  days   in  a  weak  solution  of  chromic   acid,  then   in    absolute 
alcohol,  and  should  then  be  embedded  in  gum  or  glycerine-glue. 
1  Volkman,  Klinisdie  Vortrdge,  i.,  No.  26. 


58  PATHOLOGY  OF   THE  EAR. 

Malformations.  Congenital  absence  of  the  drum- 
membrane,  as  an  isolated  malformation,  without  sim- 
ultaneous absence  of  the  osseous  meatus,  is  doubtful. 
Itard,  Claude  Bernard,  Bonnafont,^  and  Erhard,^  claim 
to  have  seen  cases  where  there  was  no  dividing  line 
between  the  meatus  and  the  tympanum,  and  the  lining 
membrane  of  both  was  of  the  same  character  and 
color.  Mistaking  an  acquired  loss  of  the  membrane 
for  congenital  absence,  is  very  easy,  because  in  such 
cases  the  epidermal  covering  of  the  meatus  often  ex- 
tends over  the  mucous  membrane  of  the  tympanum. 
It  is  certain  that  absence  is  often  considered  to  be 
congenital  where  it  has  clearly  been  caused  by  dis- 
ease, as,  for  instance,  in  the  case  of  Elsasser.^  Con- 
genital absence  of  the  membrane  must  certainly  be 
very  rare.  I  myself  have  never  seen  an  instance  of 
it. 

The  existence  of  congenital  double  membrana  tym- 
pani  is  also  very  doubtful.  The  examples  of  it  given 
by  Duverney,  Koehler,  and  Oberteuffer  are  in  reality 
membranous  new  growths  in  the  meatus. 

As  the  upper  portion  of  membrana  tympani  in 
the  very  young  embryo  is,  according  to  Huschke,  not 
closed,  it  may  happen,  in  very  rare  cases,  that  in 
adults  an  arrest  of  development,  in  the  shape  of  an 
opening  in  the  upper  portion  of  the  membrane,  may 
be  seen.  This  corresponds  in  analogy  with  the  colo- 
boma  iridis.  It  is  produced  by  the  flxilure  of  the  true 
membrana  tympani  to  unite  with  the  membrana  flac- 
cida.      Such  openings  are  sometimes  found   on  both 

1  Lehrhuch,  11.  Auflage,  S.  275. 

2  Rauonelle  Oliatrik,  S.  U. 

3  Hufeland's /owrnaZ  (Z.  Pmct.  Heilkunde,  1828,  II.  7,  S.  123,  note. 


THE  DRUM-MEMBRANE.  59 

sides  and  associated  with  other  forms  of  arrest  in  de- 
velopment (cleft  uvula,  Von  Troeltsch).  The  so- 
called  foramen  Rivini,  described  in  1717  by  Professor 
Rivinus  of  Leipzig,  and  previously  by  Professor  Mar- 
chetti  of  Padua,  in  1652,  was  for  a  long  time  the 
source  of  active  controversy.^  It  was  described  as  a 
normal  attribute  of  the  drum-membrane,  even  very 
recently  by  Professor  Bochdalek,  of  Prague  (1866^). 
It  was  sometimes  referred  to  the  middle,  sometimes 
to  the  up2)er  portion  of  the  membrane. 

A  normal  foramen  Bivini  does  not  exist.  In  most 
cases  where  such  an  opening  exists,  and  it  is  by  no 
means  uncommon  in  the  membrana  flaccida  Schrapneli 
which  is  not  involved  in  the  functions  of  the  ear,  it 
is  the  result  of  previous  inflammation  ;  only  in  very 
rare  cases  is  it  in  man  a  congenital  arrest  of  develop- 
ment, although  in  the  insect-eating  animals  it  is  more 
common.'^ 

Anomalies  in  form,  size,  and  inclination  of  the 
membrane  are  frequent,  but  of  no  importance. 
Among  the  numerous  varieties  in  form,  the  most  note- 

^  The  existence  of  the  foramen  Eivini  is  denied  by  liildehrandt, 
Mayer,  Meckel,  Rudolphi,  Cornelius,  Cloquet,  Linke,  Engel;  it  is 
doubted  by  Ruyscli,  Pauli,  Walther,  Cassebohm,  Haller  ;  it  is  main- 
tained by  Colle,  Marchetti,  Glaser,  Rivinus,  Munniks,  Cheselden,  Teich- 
niayer,  Scarpa,  Berres.  The  opening  is  regarded  as  merely  an  excep- 
tional arrest  of  development  by  Buschke,  Hyrtl,  Dursy. 

2  Prager  Vierteljahrssch:,  1866,  Bd.  I.,  S.  33-46.  Bochdalek,  Jun., 
affirms  the  existence  of  Rivinian  openings  or  canals  (Oesterr.  Zeitsclir. 
fur  Prakt.  Heilkunde,  1866,  Nos.  32,  33).  He  considers  only  the  anterior 
canal  to  be  perfectly  constant,  and  this  opens  into  the  anterior  pouch 
of  the  drum-membrane.  The  external  opening  in  the  drum-membrane 
is  surrounded  by  a  projecting  distinctly  fibrous  ring  when  examined  mi- 
croscopically. 

^  Bonnafont  (Traite,  etc.,  p.  273)  has  twice  seen  congenital  openings 
in  the  drum-membrane. 


60  PATHOLOGY  OF   THE  EAR. 

worthy  is  the  triangdar  form  described  by  Koehler.^ 
The  size  of  the  membrane  depends  on  the  variable, 
individual  width  of  the  meatus.  The  normal  di- 
ameter of  the  elliptical  membrane  is  9-10  mm.  in 
its  greatest  length,  and  8.7-9.4  mm.  in  its  greatest 
breadth. 

Among  the  anomalies  of  inclination  should  be  men- 
tioned the  very  perpendicular  position  of  the  drum- 
membrane  as  seen  often  in  very  musical  people  ;  and 
the  nearly  horizontal  position  of  the  membrane  (nor- 
mal in  the  new-born  child)  as  seen  in  adults  with 
congenital  deafmutism  and  with  cretinismus.  Von 
Troeltsch^  thinks,  that  from  the  degree  of  inclination 
•of  the  drum-membrane,  it  is  perhaps  possible  to  judge 
of  the  higher  or  lower  position  of  the  sphenoid  bone 
and  of  the  degree  of  perfection  of  the  skull  in  gen- 
eral ;  in  other  words,  that  there  seems  to  be  a  legiti- 
mate connection  between  the  anomalies  of  inclination 
in  the  drum-membrane,  and  those  of  development 
in  the  base  of  the  skull.  In  the  normal  meatus  of 
adults,  the  averao;e  normal  ang-le  of  the  drum-mem- 
brane,  i.  e.,  the  angle  which  the  membrane  forms 
with  the  upper  (or  posterior)  wall  of  the  meatus,  is 
given  by  Von  Troeltsch  as  140°. 

Congenital  anomalies  of  inclination  should  not  be 
confounded  with  acquired  anomalies  of  curvature,  as 
frequently  happens  in  an  examination  by  inexperi- 
enced persons. 

The  manubrium  may  be  inserted  into  the,  mem- 
brana  propria  in  a  false  direction,  for  instance,  it  may 

^  Besclireibung   der  Loder^schen   Sammlung,    Leipzig,    1795,    S.     188, 
No.  582. 

2  Lchrhuch,  V.  Auflaiie,  S.  39. 


THE   DRUM-MEMBRANE.  61 

be  directed  forwards  and  downwards,  or  it  may  be 
curved  like  a  sabre  throuo;hout  its  whole  leng-th,  or 
merely  at  its  lower  end. 

Hyperaemia.  On  the  normal  drnm-membrane  and 
along  the  manubrium  no  blood-vessels  are  visil)le  ; 
but  temporary  and  slight  irritation  of  the  skin  of  the 
meatus,  or  a  touch  on  the  membrana  tympani,  are 
sufficient  to  produce  momentary  injection  of  the  ves- 
sels of  the  manubrium.  Where  these  vessels  appear 
permanently  congested  and  enlarged,  in  the  form  of 
a  bright  or  light  red  bundle  of  vessels  along  the  pos- 
terior edge  of  the  manubrium,  or  wholly  covering 
that  bone,  it  is  either  a  sign  of  inflammatory  irritation 
in  the  drum-membrane  or  tympanum,  or  else  a  symp- 
tom of  habitual  congestion  of  the  head. 

This  hyperaemia  in  the  vicinity  of  the  hammer  fre- 
quently appears  as  a  direct  extension  of  a  h^qoersemia 
of  the  walls  of  the  meatus.  In  its  higher  degrees  it 
is  not  confined  to  the  immediate  neighborhood  of  the 
manubrium,  but  extends  over  a  triangular  portion  of 
the  drum-membrane  near  that  bone,  the  base  of  the 
triangle  being  directed  upwards. 

Passive  hyperemia  in  the  venous  ring  on  the  pe- 
riphery of  the  membrane  is  a  common  appearance 
with  hyperaemia  of  the  tympanic  mucous  membrane. 
When  it  is  very  marked,  nmnerous  radiating  vessels 
are  seen  in  the  cutis  of  the  drum  membrane  anasto- 
mosing with  the  vessels  of  the  manubrium,  becoming 
wider  as  ih^y  extend  outwards,  and  finally  joining 
the  venous  ring  on  the  periphery.  In  the  highest 
stage  of  hypera3mia  of  the  cutis  of  the  drum-mem- 
brane the  single  capillaries  are  no  longer  seen,  but 
the  membrane  has  a  diffuse  red  color,  the  intensity  of 


62  PATHOLOGY  OF   THE   EAR. 

which  varies,  according  to  the  degree  of  hyperaemia, 
from  pink  to  blnish  red,  copper  red,  and  scarlet. 
Such  hyperoemias  of  the  skin  are  often  seen  without 
hyperemia  of  the  mucous  membrane ;  when  they  are 
present  the  hammer  is  not  visible.  With  normal  or 
increased  transparency  of  the  drum-membrane,  a  vio- 
let appearance  may  be  given  to  the  membrane  by 
reflection  from  the  hypercemia  of  the  labyrinthine 
wall  of  the  tympanum,  the  drum-membrane  itself  not 
participating  in  the  hypercemia.  With  muco-puru- 
lent  catarrh  of  the  tympanum  without  perforation, 
the  hyperemia  of  the  drum-membrane  is  sometimes 
confined  to  its  mucous  layer ;  this  is  more  especially 
the  case  on  the  periphery  or  on  certain  isolated  spots 
of  the  membrane.  In  the  majority  of  cases,  however, 
both  the  skin  and  the  mucous  layer  of  the  membrane 
are  simultaneously  hyperaemic.  The  lamina  propria 
is  either  entirely  destitute  of  vessels,  or  is  perforated 
at  its  edge  by  single  small  capillaries. 

Hemorrhage.  Spontaneous  and  traumatic  hemor- 
rhage in  the  substance  of  the  membrana  tympani  is 
seen  as  minute  ecchymoses,  superficial  extravasations, 
haematomata  and  hemorrhagic  infiltrations,  and  may 
occur  either  in  the  layer  of  skin  or  of  mucous  mem- 
brane, sometimes  in  both  simultaneously.  It  is  found 
with  simultaneous  hyperaemia  of  the  tympanic  mucous 
membrane  during  measles,  small-pox,  typhus,  scurvy, 
from  compression  of  the  lungs  by  pleuritic  exudation, 
and  from  other  causes  which  produce  congestion  of 
the  vena  cava  superior,  from  endocarditis  and  also 
from  primary  inflammations  of  the  drum-membrane. 
The  hemorrhages  may  occur  just  in  front  of  or  be- 
hind the  manubrium,  in  the  posterior  upper  part  of 


THE  DRUM-MEMBRANE.  G3 

the  membrane,  and  also  at  other  spots.  Hemor- 
rhagic infiltration  is  sometimes  found  on  the  edges 
of  perforations,  and  appears  as  an  ill-defined  bluish- 
black  thickening  of  the  edges.  Ha3matoma  in  the 
mucous  layer  appears  as  a  bluish-red,  sharply  defined, 
round  or  oval  prominence  above  the  plane  of  the 
mucous  membrane.  It  was  first  described  by  Wendt,^ 
who  found  it  in  the  dissection  of  small-pox  cases.  The 
remains  of  extravasations  I  have  often  seen  as  gray- 
ish-black pigmentations  of  the  mucous  layer,  like  the 
pigmentation  in  the  intestinal  mucous  membrane  after 
cholera  infantum.  The  ecchymoses  which  occur  un- 
der the  epidermis  change  their  position  and  wander 
in  the  course  of  a  few  weeks  towards  the  periphery 
of  the  membrana  tympani,  generally  towards  the 
posterior  upper  wall,  and  from  there  pass  on  to  the 
skin  of  the  meatus.  This  very  peculiar  locomotion 
was  first  described  by  Von  Troeltsch,^  and  has  since 
been  noticed  in  various  ways.  It  has  been  thought 
that  its  cause  was  an  eccentric  growth  of  the  epider- 
mal covering,  while  Zaufiil  endeavors  to  explain  it  by 
capillary  action,  and  Kessel  thinks  that  the  extrava- 
sation is  within  the  lymph-vessels,  and  its  motion 
dependent  on  the  movement  in  these  vessels. 

Inflammation  of  the  Drum-Membrane  (myringitis)  and 
its  results.  An  independent  primary  inflammation 
of  the  drum-membrane  is  relatively  rare,  and  is  usu- 
ally found  only  on  one  side.  In  most  cases,  inflam- 
mation of  the  tympanum  or  of  the  meatus  is  also 
present,  and  the  inflammation  of  the  drum-membrane 
mak«s  its  appearance  as  a  secondary  affection. 

^  Arch.  f.  Heilkunde  von  Wagner,  xiii.,  S.  128. 
2  Lehrbuch,  V.  Aufl.,  S.  131,  note. 


64  PATHOLOGY   OF   THE   EAR. 

In  the  acute  form  of  myringitis,  the  membrane 
appears  flattened  and  the  manubrium  indistinct  from 
hypera^mia  and  serous  infiltration  of  the  layer  of  cutis. 
The  position  of  the  manubrium  is  only  recognized  by 
a  red  line  of  blood-vessels.  The  epidermis  is  macer- 
ated, becomes  loose  and  is  destroyed ;  owing  to  this 
the  corium  is  exposed,  and  appears  red,  loosened,  and 
swollen.  The  swelling  is  the  result  of  serous  and  cel- 
lular infiltration.  In  the  mucosa  immense  numbers 
of  cells  are  found  in  the  connective  tissue  stroma, 
and  the  blood-vessels  are  enlarged.  The  substantia 
propria  shows  a  peculiar  swelling  and  softening  of 
the  fibres  from  which  the  drum-membrane  assumes  a 
soft  relaxed  condition,  and  is  very  easily  torn.  The 
meatus  near  the  membrana  tympani,  if  not  originally 
affected,  participates  secondarily  in  the  inflammation, 
the  sharp  boundary  between  the  meatus  and  drum- 
membrane  disappears,  and  the  membrane  itself  looks 
smaller  than  natural  on  account  of  the  swelling  of  the 
meatus. 

Sometimes  ecchymoses  and  interlamellar  abscesses 
occur  in  the  membrane.  In  very 
rare  cases  perforating  ulcers  are 
found.     (Fig.  30.) 

Acute  diseases  of  the  skin  of 
the  meatus  sometimes  extend  on 
to   the    skin   of  the   drum-mem- 
brane, and  the  vesicles  of  eczema 
■"'2  ^°  and  pemphigus  have  been  seen  on 

An  Ulcer  perfovatinsr  from     • ,         -r  ^  xl  ^       1,1, ,„ 

without  inward,  in  the  central    it-       I  haVC  UCVCr  SCCH  the  plllyC- 
portion  of  tlie  drum  membrane,    teuular  foHU  of   myringitis   OCCUr- 

ring  with  scrofula  as  it  is  described  by  Triquet.^     Pos- 

1  Presse  Med.,  1863,  18. 


THE  DRUM-MEMBRANE.  65 

sibly  this  is  owing  to  its  being  confounded  with  vesic- 
ular prominences  of  the  skin  or  with  the  vesicles  of 
eczema. 

The  chronic  inflammation  of  the  membrana  tym- 
pani,  which  comes  under  observation  frequently,  is 
also  seldom  an  isolated  disease,  but  is  usually  only  an 
accompaniment  of  simultaneous  inflammation  of  the 
tympanum.  The  membrane  is  covered  with  pus,  is 
thickened,  flattened,  of  a  yellowish  gray  color,  with 
radiating  varicose  blood-vessels,  and  occasionall}''  with 
polypoid  excrescences.  No  part  of  the  hammer, 
except  perhaps  the  processus  brevis,  can  be  recog- 
nized. In  the  substantia  propria  there  are  deposits 
of  fat  and  lime,  in  the  mucous  membrane  infiltration 
with  round  cells ;  cysts  also  are  sometimes  formed. 

The  walls  of  the  meatus  are,  in  their  external  half, 
of  nearly  normal  appearance,  in  their  inner  half,  near 
the  drum-membrane,  usually  covered  with  black  crusts, 
but  nowhere  with  fresh  pus. 

The  myringitis  parasitica  (myringomycosis  asper- 
gillina,  Wreden's),  described  by  Wreden  as  an  inde- 
pendent disease,  is  only  one  of  the  appearances  of 
otomycosis.^ 

Nassiloff  ^  has  given  the  name  myringitis  villosa  to 
a  form  of  chronic  inflammation,  in  which  ijairillary 
outgrowths  or  villi  from  0.06  —  0.25  mm.  in  length 
are  developed  on  the  external  surface  of  the  mem- 
brane with  an  increase  of  vascularity ;  at  the  same 
time  the  fibres  of  the  drum-membrane  may  be  sup- 
planted by  a  new  growth  of  a  vascular  connective 
tissue  in  the  cutis  and  membrana  propria. 

1  Vide  p.  56, 

^Med.  Centralblatt,  1SG7,  No.  11. 
5 


66  PATHOLOGY   OF   THE   EAR. 

According  to  Nassiloff,  these  villi  are  covered  with 
several  layers  of  pavement  epithelium ;  according  to 
Kessel,  by  a  single  layer  of  cylinder  epithelium,  with 
peculiar  variations  in  form.  Both  are  apparently 
only  different  stages  of  development  of  the  same  new 
growths,^  and  are  analogous  to  the  polypoid  inflam- 
mations of  the  mucous  membrane. 

As  results  of  inflannnation  of  the  membrana  tym- 
pani  should  be  mentioned  :  — 

1.  Anomalies  of  color  and  trajisjxirenci/.  Aside 
from  individual  variations  in  color  and  transparency 
which  the  healthy  drum-membrane  may  offer,  ojKici- 
ties  and  thickenings  are  often  found  as  the  result  of 
inflammatorj'  processes.  The  smoky-gray  or  pearl- 
gray  color  of  the  normal  membrane  may  become  deep 
gray,  whitish  gra}^,  yellow,  or  yellowish  red.  All 
these  variations  of  color  are  seen  much  more  pro- 
nounced on  examining  living  subjects  than  they  are 
on  the  dead  body,  where  they  are  indistinct  if  the 
preparation  is  not  perfectly  fresh,  and  have  often 
wholly  disappeared  if  the  preparation  has  been  in 
spirit. 

The  transmission  of  color  from  the  contents  of  the 
tympanum,  whether  due  to  abnormal  conditions  of 
its  mucous  membrane  or  to  the  collection  of  secre- 
tion in  the  cavity,  have  an  important  influence  on 
the  changes  of  color.  The  infantile  drum-membrane, 
on  account  of  the  greater  thickness  of  its  cutis  and 
mucous  layers,  always  appears  a  thicker  whitish  gray 
than  does  the  membrane  of  adults,  and  it  is  possible 
that  this  variation  from  the  normal  color  sometimes 
continues  till  adult  life  as  an  anomaly  of  development. 

1  S.  Kessel,  Zur  Myringitis  Villosa.     A.  f.  0.,  v.,  S.  250. 


THE   DRUM-MEMBRANE.  67 

In  old  age  a  whitish  discoloration  of  the  membrane 
is  by  no  means  to  be  referred  to  the  physiological 
changes  due  to  age.^ 

Opacities  do  not  always  correspond  with  thicken- 
ings of  the  membrane,  but  are  also  found  with  atro- 
phic processes.  According  to  their  extent,  position, 
and  form,  we  distinguish  partial  and  total  opacities, 
peripheral  and  intermediar,  crescentic,  speckled,  stri- 
ated, etc. 

The  histological  substratum  of  opacities  is  variable  ; 
most  frequently  it  is  a  new  growth  of  connective 
tissue  together  with  changes  in  the  superficial  layer 
of  epithelium,  such  as  deposition  of  fat  and  lime,  albu- 
minous infiltration,  or  else  a  new  growth  of  connec- 
tive tissue  in  the  lamina  propria.  It  is  rare  that  a 
single  layer  of  the  drum-membrane  is  the  seat  of  an 
opacity  ;  usually  all  three  layers,  on  account  of  their 
intimate  relations,  are  simultaneously  affected  by  the 
pathological  processes.  Thickenings  generally  occur 
from  an  increase  in  the  thickness  of  the  superficial 
layers  of  the  membrane,  rarely  of  the  fibrous  middle 
layer.  (The  normal  thickness  of  the  membrane  is 
0.1  mm.) 

Partial  opacities  most  commonly  begin  in  the  sub- 
stantia propria,  but,  with  very  few  exceptions,  ex- 
tend from  that  into  both  the  superficial  layers.  They 
appear  as  irregular  yellowish-white  or  white  specks 
and  lines,  at  first  with  indistinct,  later  wdth  sharply 
defined  edges.  They  are  caused  by  fatty  degenera- 
tion of  the  membrana   propria  itself,   or  by   a   new 

^  Gruber  describes,  as  a  frequent  appearance  in  old  age,  a  periphei-al 
yellowish  or  milky  opacity,  winch  is  usually  due  to  fatty  degeneration 
of  the  substantia  propria.  —  Lehrbuch,  p.  398. 


68  PATHOLOGY  OF   THE  EAR. 

growth  of  connective   tissue  between   the  fibres   of 
that  membrane,  thus  crowding  these  fibres  together. 

A  crescentic  intermedlar  opacity  behind  the  manu- 
brium, the  convexity  directed  towards  the  periph- 
ery, is  a  frequently  recurring  variety.  It  often 
exists  with  simultaneous  hypertrophy  and  adhesive 
inflammation  of  the  mucous  membrane  (synechiae 
within  the  tympanum).  Some  intermediar  opacities, 
it  should  be  stated,  are  only  optical  appearances  on 
the  membrana  tympani,  and  disappear  whenever  the 
drum-membrane  can  be  examined  perpendicularly  to 
its  surface.  In  other  cases  partial  opacities  in  the 
form  of  irregular  specks  and  striaa  (tendinous  opaci- 
ties) are  seen,  which  inclose  atrophic  spots  in  the 
membrane.  These  are  found  more  especially  with 
rigidity  and  anchylosis  of  the  ossicles. 

The  so-called  j)eri2)heral  ojKiclties  are  peripheral, 
whitish-gray  opacities,  varying  very  much  in  the  in- 
tensity of  their  color ;  they  are  produced  by  a  depo- 
sition of  fat-globules  between  the  circular  fibres  of 
the  lamina  propria,  which  fibres  are,  in  the  normal 
condition,  closely  crow^led  together  on  the  periphery 
of  the  membrane  ;  or  else  they  are  caused  by  a  thick- 
ening of  the  mucous  layer  of  the  membrane,  which 
in  this  region  possesses  in  the  normal  condition,  villi 
or  papillae,  as  was  first  described  by  Gerlach. 

When  these  peripheral  opacities  are  very  well 
marked  there  always  exists  a  simultaneous  patholog- 
ical thickening  of  the  tympanic  mucous  membrane, 
and  it  will  be  noticed  that  the  central  portion  of  the 
membrana  tvmpani  appears  darker  and  more  trans- 
parent than  usual,  and  apparently  or  in  reality  is 
curved  deeper  inwards  than  is  natural. 


THE  DRUM-MEMBRANE. 


G9 


Calcifications  in  the  membrana  tympani  are  very 
common.  They  may  occur  as  isolated  affections  with- 
out pathological  changes  in  the  deeper  parts  of  the 
ear  and  with  a  normal  hearing  ;  more  commonly  they 
are  the  remains  of  previous  suppurative  processes  in 
the  ear,  but  they  are  also  found  in  deaf  persons  with 
non-suppurative    inflammations    of   the    middle    ear. 


Ffg.  3 


Fig.  32. 


Fig.  33.  Fig   34. 

Fig.  31.     Calcification.^  in  the  Drum-membrane. 

Figs.  32  and  33.     Calcitications  and  Cicatrices. 

Fig.  34.  Calcitication  of  the  whole  Drum-membrane  seen  from  within,  with  a  cic- 
atricial formation  in  the  posterior  upper  quadrant.  The  calcified  membrane  projects 
sharply  into  the  tympanum  and  is  as  hard  as  bone. 

The  most  common  form  of  calcification  is  a  crescent 
before  or  behind  the  manubrium  ;  the  horse-shoe  vari- 
ety is  less  common.  In  the  highest  degrees  of  calcifi- 
cation the  deposit  extends  over  the  whole  memlsrane, 
but  this  occurs  only  after  suppurative  processes.  The 
drum-membrane  is  then  transformed  into  a  perfectly 
rigid  stony  plate,  sometimes  of  considerable  thick- 
ness (2-3  mm.). 


70  PATHOLOGY  OF   THE  EAR. 

Besides  the  crescentic  form  the  deposits  of  lime  oc- 
cur as  irregular  and  radiating  striations  from  the  end 
of  the  manubrium  towards  the  periphery  of  the 
drum-membrane , 

A  central  calcification  surrounding  the  manubrium 
is  very  rare.  Beginners  in  otoscopy  can  easily  mis- 
take the  yellow  appearance  of  the  end  of  the  manu- 
brium, which  is  visible  under  normal  conditions,  for  a 
calcification. 

The  seat  of  calcification  is  either  the  lamina  propria 
alone,  in  which  case  the  superficial  layers  of  the 
drum-membrane  are  easily  separated  under  water  by 
means  of  needles  from  the  calcification,  or  else  all 
three  layers  of  the  drum-membrane  are  calcified  ;  in 
this  latter  case  the  deposit  often  projects  above  the 
surface  of  the  mucous  membrane,  rarely  above  that 
of  the  skin. 

The  thickened  epidermis  of  the  membrana  iym- 
pani  appears  to  be  very  rarely  indeed  the  sole  seat 
of  lime  deposits  (Lucae). 

The  deposition  of  amorphous  lime-particles  takes 
place  in  the  membrana  propria,  partially  between  and 
in  its  fibres,  partially  in  the  drum-membrane  corpus- 
cles ;  with  the  lime  there  is  usually  much  fat,  seldom 
any  pigment.  According  to  Wendt,  the  deposition 
occurs  in  the  endothelial  sheaths  wdiich  surround,  like 
a  tube,  the  processes  of  the  fibrous  framework  of  the 
membrane.  The  histolocrical  chanojes  near  the  calci- 
fied  spots  extend  further  than  would  be  supposed 
from  the  clearly  defined  edges  of  the  deposit.  Ex- 
ceptionally crystallized  lime  is  found,  as  was  first 
described  by  Von  Troeltsch.^     Bauer  -  found  crystals 

^   Virchow's  Archiv,  xvii.,  S.  16. 
^  Diss.  Inauf/.,  1863,  Marburg. 


THE  DRUM-MEMBRANE.  71 

of  phosphate  of  lime  in  the  membrana  tympani  of 
hemicephali.  with  deposits  of  the  same  salt  in  the 
tympanum  and  laljyrinth,  and  the  stapes  was  com- 
pletely imbedded  in  a  solid  crystalline  mass  of  lime. 
Liicae^  found  crystals  of  carbonate  of  lime  (aragonite) 
in  the  peripheral  portion  of  the  thickened  epidermis 
of  the  membrana  tympani  in  a  case  of  chronic  catarrh 
of  the  middle  ear. 

The  existence  of  a  7iew  growth  of  hone  near  cal- 
cified portions  of  the  membrana  tympani  in  man 
was  first  proved  by  the  histological  investigations  of 
Politzer,  and  was  later  confirmed  by  Wendt  from  his 
own  dissections.  Microscopically  large  and  numer- 
ous bone  corpuscles  with  short  processes  are  seen. 

Partial  opacities  may,  finally,  be  produced  accord- 
ing to  Gruber,^  by  a  duplicature  of  the  drum-mem- 
brane and  the  union  of  the  mucous  surfiices  by  con- 
nective tissue.  They  result  from  long  continued 
closure  of  the  Eustachian  tube,  are  usually  situated 
in  the  posterior  segment  of  the  membrane,  pass  back- 
wards in  a  curve  from  the  processus  brevis  and  re- 
semble a  strongly  developed,  so  called  posterior  fold. 
The  affected  segment  of  the  membrana  tympani  ap- 
pears diminished  in  size  and  is  opaque.  Partial  opac- 
ities produced  in  the  same  way  may,  according  to 
Gruber,  also  occur  on  the  anterior  seo'ment  and  as- 
sume  a  circular  shape. 

Similar  opacities  can  be  produced  by  a  growth  on 
the  mucous  membrane  or  by  a  union  of  the  pouches 
of  the  membrana  tympani. 

Total  ojmcities  of  the    drum-membrane  are  most 

^   Virchow's  ArcJiiv,  xxxvi.,  June. 
2  Lekrbuch,  S.  402. 


72  PATHOLOGY  OF   THE  EAR. 

frequently  produced  by  a  thickening  of  the  mucous 
membrane,  one  of  the  results  of  the  general  thicken- 
ing of  the  whole  tympanic  mucous  membrane  which 
occurs  from  chronic  catarrhs.  The  thickening  of  the 
mucous  layer  of  the  drum-membrane  may  be  so  ex- 
treme as  to  be  five  times  the  normal  thickness  (0.1 
mm.)  of  all  the  layers  together.  The  thickening  is 
caused  by  enlargement  of  the  blood-vessels  and  the 
presence  of  large  numbers  of  cells  in  the  connective 
tissue  stroma.  The  epithelium  remains  intact.  Ex- 
amined externally  during  life  the  membrana  tympani 
appears  in  such  cases  bluish-white  or  fibrous,  resem- 
bling a  slightly-ground  glass  (Politzer).  The  manu- 
brium remains  visible  or  its  contour  is  even  more  dis- 
tinct than  on  the  normal  membrane,  so  long  as  the 
external  layers  are  unaffected.  In  most  cases  such 
thickening  of  the  mucous  layer  is  complicated  by  cir- 
cumscribed or  diffiise  secondary  opacities  of  the  lam- 
ina propria  or  of  the  skin. 

Total  opacities  may  also  occur  from  a  loosening 
and  thickening  of  the  epidermis,  from  swelling  of 
the  cutis  layer,  by  which  the  hammer  is  rendered  in- 
visible, and  from  untransparency  of  the  lamina  pro- 
pria alone.  Thickenings  of  the  epidermal  layer  are 
usually  the  result  of  the  different  forms  of  otitis  ex- 
terna, but  are  also  produced  by  suppuration  of  the 
tympanum  with  perforation  of  the  drum-membrane. 
From  the  serous  infiltration  and  thickening  of  the 
epidermis,  the  membrana  tympani  appears  grayish- 
white,  without  lustre,  flattened  and  rough.  In  the 
highest  stages  of  the  disease  the  epidermis  is  com- 
pletely macerated.  Diffiise  swelling  of  the  dermis  is 
produced  by  the  enlargement  of  the  blood-vessels  and 


THE  DRUM-MEMBRANE.  73 

the  deposition  of  pus  cells  between  the  meshes  of  con- 
nective tissue ;  diffuse  opacity  of  the  lamina  propria 
by  translucent  swelling,  albuminous  infiltration  or 
fatty  degeneration  of  the  fibres  of  the  drum-mem- 
brane, and  by  the  deposition  of  calcareous  molecules. 
Exceptionally,  Politzer  found  an  unusual  number  of 
the  normal  fibres  constituting  the  histological  sub- 
stratum of  opacities  in  the  lamina  propria. 

2.  Anomalies  of  Curvature 
May  appear  as  convex  projections,  as  flattening  or  as 
increased  concavity  (drawing  inwards)  of  the  drum- 
membrane. 

Convex  j^'^ojectlons,  the  result  of  inflammatory 
swelling  with  acute  catarrh  of  the  tympanum,  seldom 
involve  the  wdiole  extent  of  the  membrane.  The 
membrana  tympani  projects  in  the  shape  of  a  hemi- 
sphere, is  bluish-red,  moist  and  glis- 
tening, resembling  the  surface  of  a 
smooth  polypus.  With  this  condi- 
tion of  the  drum-membrane,  the 
position  of  the  manubrium  may  be 
indicated  by  a  groove  between  the 
anterior  and  posterior  segments  of  p's  35. 

the  projection.  Bladder-Uke    Piotnision 

.  .        .  pi  ""     ^^^    Posterior    Upper 

Jrartial  IWOjectlOnS    of     the  mem-    Quadrant;   from  collection 

brane  are  very  common  from  collec-  f  '""'^"''°"  '" ^^'^ '^^^"'^ 

•'^  tympani. 

tion  of  exudation  in  the  tympanum, 
and  also  during  acute  myringitis  ;  they  are  most  com- 
mon near  the  periphery  and  on  the  upper  half  of  the 
membrane,  often  appearing  as  bladder-like  projections 
on  the  periphery  of  the  posterior  upper  quadrant. 
They  are  also  produced  by  granulations,  infiltrations. 


74  PATHOLOGY  OF   THE  EAR. 

and  abscesses  in  the  clrmn-memlDrane.  by  the  collection 
of  pus,  mucus,  caseous  and  epidermal  masses  behind 
the  membrane,  and   by  polypi  within  the  tympanum. 

The  granulations  of  the  membrana  tympani  are. 
papillary  connective-tissue  growths  of  the  cutis  layer, 
and  certain  portions  or  even  the  whole  membrane 
may  be  thus  affected.  They  are  more  common  during 
otitis  media  purulenta  with  perforation  than  during 
chronic  otitis  externa,  without  perforation. 

The  partial  projections  of  the  drum-membrane, 
which  are  sometimes  produced  by  collections  of  air 
under  its  skin,  and  by  hernial  openings  in  the  mem- 
brane, will  be  considered  with  atrophy  of  the  mem- 
brane. 

Flattening,  by  which  the  drum-membrane  loses  its 
normal  concavity  around  the  umbo,  and  appears  as  a 
flat  disk,  results,  1.  From  swelling  of  its  layer  of 
skin,  which  often  occurs  with  swelling  of  the  layer 
of  mucous  membrane ;  2.  From  collections  of  exuda- 
tion behind  the  membrane  ;  3.  From  inaction  of  the 
tensor  tympani,  as  in  fatty  degeneration,  atrophy, 
etc.,  of  that  muscle. 

Increased  concavity  (abnormal  drawing  inwards, 
collapse,  depression).  A  normal  membrana  tympani 
shows  on  dissection  an  increased  concavity  so  long  as 
the  rigor  mortis  of  the  tensor  tympani  continues. 

Pathological  concavity  is  produced  by  every  long 
continued  closure  of  the  Eustachian  tube  ;  also  by 
synechise  of  the  membrana  tympani  or  of  the  manu- 
brium with  the  labyrinthine  wall,  or  with  the  floor 
of  the  tympanum ;  ^  by  peripheral  thickening  of  the 

^  By  synechia  between  the  drum-membvane  and  the  labyrinthine 
wall,  the  tympanum  may  be  divided  into  two  parts,  the  anterior  comniu- 


THE  DRUM-MEMBRANE.  75 

layer  of  mucous  membrane  and  by  shortening  of  the 
tendon  of  the  tensor  tympani  muscle,  resulting  from 
retraction  of  the  thickened  mucous  membrane  which 
covers  it. 

With  a  pathological  increased  concavity,  the  color 
of  the  drum-membrane  may  remain  unchanged,  or  it 
may  be  modified  by  the  transmitted  color  of  the  tym- 
panic mucous  membrane,  or  it  may  be  dark  gray, 
from  opacity  of  the  drum-membrane  itself.  The  lus- 
tre is  often  increased  ;  the  triangular  light  reflex  is 
widened  and  pushed  towards  the  periphery,  and  often 
there  is  a  striated  light  reflex  on  the  anterior  lower 
portion  of  the  periphery  of  the  membrane. 

The  characteristics  of  increased  concavity  of  the 
whole  membrane  when  examined  from  the  meatus, 
are  perspective  foreshortening  of  the  manubrium,  ab- 
normal prominence  of  the  short  process  and  the  axis- 
ligaments,  more  especially  the  posterior  ligament, 
ligamentum  mallei  posticum  (Helmholtz).  Seen  from 
within  the  central  portion  of  the  drum-membrane  is 
funnel-shaped,  and  lies  close  to  the  labyrinthine  wall 
of  tlie  tympanum. 

The  so-called  posterior  fold  of  the  membrana  tympani,  which, 
when  very  pronounced,  has  been  considered  as  diagnostic,  of  in- 
creased concavity,  is  not  a  true  fold,  but  a  slight  angular  promi- 
nence of  the  membrane,  as  the  result  of  which  a  curved  projecting 
ridge  of  membrane  is  found  running  from  the  short  process  back- 
wards, as  Von  Troeltsch  rightly  described  it  in  the  first  edition  of 
his  work  (1862,  S.  148). 

In  the  natural  position  of  the  membrane,  the  hammer  always  ap- 
pears, on  inspection,  during  life,  shorter  and  smaller  than  it  really 
is.     This  is  shown  very  clearly  on  dissection,  if  the  membrana  tym- 

iiicating  with  the  Eustachian  tube,  the  posterior  with  the  mastoid  pro- 
cess. 


76  PATHOLOGY   OF    THE   EAR. 

pani  is  examined  before  and  after  removal  of  the  meatus.  In  a 
pathological  sense,  perspective  foreshortening  is  only  used  when 
there  is  a  pathological  increase  in  the  concavity  of  the  membi-ane. 
The  perspective  foreshortening  is  seen  in  its  highest  degree  with 
the  maximum  concavity  of  the  membrane,  that  is,  in  those  cases  in 
which  the  membrane  lies  against  the  labyrintli  wall.  With  the 
lesser  degrees  of  foreshortening,  there  is  very  often  also  a  perspec- 
tive diminution  in  the  size  of  the  manubrium,  because  the  anterior 
half  of  the  membrane  is  more  strongly  drawn  inwards  than  the 
posterior  half.  When  there  is  large  destruction  of  the  drum-mem- 
brane in  the  neighborhood  of  the  hammer,  the  manubrium  may  lie 
so  nearly  horizontal  that  only  tlie  short  process,  with  its  point  di- 
rected downwards,  is  visible  externally. 

For  an  account  of  partial  concavities,  see  Cicatrices 
(p.    80),  and    Atrophy  of  the   Memhrana  Tympani, 

(p.  85). 

3.  Perforations  and  Cicatricial  Formations. 

Perforations  occur  in  all  parts  of  the  inembrana 
tympani ;  are  most  common  on  the  anterior  lower 
quadrant  of  the  membrane  in  the  intermediar  zone 
between  the  manubrium  and  the  tendinous  tympanic 
ring;  are  most  rare  immediately  at  the  manubrium  or 
periphery  because  at  these  spots  the  lamina  propria 
is  most  strongly  developed  and  offers  the  greatest  re- 
sistance to  destructive  processes  (Politzer).  Perfora- 
tions in  the  extreme  upper  portion  of  the  membrane, 
in  the  so-called  membrana  flaccid  a  Shrapneli,  where 
there  is  no  lamina  propria,  are  by  no  means  rare. 

The  size  of  perforations  vary  from  that  of  a  fine 
needle  to  a  loss  of  the  whole  membrane.  Most  com- 
monly a  Y  shaped  portion  of  the  membrane  remains 
above  and  around  the  manubrium  and  a  falciform 
remnant  on  the  periphery. 

The  most  common  shape  of  perforations  is  round, 


THE  DRUM-MEMBRANE. 


77 


oval,  elliptical,  or  kidney-shaped.  With  a  central  per- 
foration the  exposed  manubrium  is  drawn  inwards  by 
the  tension  of  the  tendon  of  the  tensor  tympani  mus- 
cle, and  lies  near  or  directly  against  the  promon- 
tory ;  in  many  cases  it  is  even  drawn  so  far  inwards 


Fig.  36. 


Fig.  37. 


Fig.  38. 


Fig.  36. 
edges. 
Fig.  .37. 
Fig.  38. 


Fig.   39.  Fig.  40. 

An   old   Circular  Perforation   of  the  Drum-membrane   with  thickened 


Kidney-shaped  Perforation. 

Large  Kidney-shaped  Loss  of  the  Membrane,  the  manubrium  exposed 
and  a  deposit  of  lime  in  the  remnants  of  the  drum-membrane. 

Fig.  39.     Loss   of  the  whole  Drum-membrane  ;  retention  of   the  exposed  manu- 
brium and  of  the  tendinous  ring. 

Fig.  40.     Loss   of  the  Drum-membrane,  the  manubrium  exposed   and  necrosed. 
Tlie  head  of  the  stapes  visible.     In  the  membrana  Shrapneli  is  a  deeply  sunken  cica- 


and  upwards  that  on  inspection  from  the  meatus  it 
appears  to  have  entirely  disappeared.  In  other  cases 
the  lower  end  nppears  to  be  shortened  from  absorp- 
tion, or  the  whole  manubrium  up  to  the  head  of  the 
hammer  is  wantinar. 


78  PATHOLOGY   OF   THE  EAR. 

In  by  far  the  greater  number  of  cases  the  perfora- 
tion takes  place  from  within  outwards  during  otitis 
media  purulenta,  but  occasionally  from  without  in- 
wards by  perforating  ulcer,  or  as  the  result  of  an  ab- 
scess of  the  membrane  during  myringitis.  Various 
conditions  unite  in  producing  these  perforations,  in- 
flammatory softening  of  the  tissues  of  the  drum-mem- 
brane, pressure  of  the  exudation  behind  the  drum- 
membrane,  and  movement  caused  by  expiration.  At 
first  only  a  rupture  occurs ;  the  edges  of  this  then 
ulcerate  and  the  loss  of  substance  is  produced.  The 
extent  of  this  loss  of  substance  depends  very  much  on 
constitutional  conditions.  The  largest  and  most  rapid 
destructions  occur  in  scrofula,  tuberculosis,  and  espe- 
cially in  scarlet  fever. 

Spontaneous  atrophy,  or  atrophy^  of  the  mem- 
brana  tympani  from  any  pressure  upon  it,  without 
the  existence  of  suppurative  inflammation,  is  a  very 
rare  cause  of  perforation.  When  it  does  occur  the 
whole  drum-membrane  appears  extremely  delicate 
and  transparent,  and  the  walls  of  the  perforation  are 
very  thin.  According  to  Beck^  there  is  a  predisposi- 
tion to  atrophic  perforation  of  the  drum-membrane  in 
old  age. 

Fresh  perforations  show  irregular,  rough,  ragged 
edges,  old  ones  smooth,  thinned  or  thickened,  or  occa- 
sionally calcified  edges,  the  thickening  being  caused 
by  development  of  blood  vessels  and  infiltration  of 
cells.  The  edges  of  the  perforations  may  be  partially 
or  completely  united  with  the  mucous  membrane  of 

1  Sfhwartze,  A.f.  0.,  ii.,  S.  291. 

2  Beck,  Krankhciten  des  Gehoroi-gans,  Heidelberg  and  Leipzig.  1827, 
S.  187. 


THE   DRUM-MEMBRANE.  79 

the  labyrinthine  wall,  either  directly  or  by  bands  of 
connective  tissue. 

Duplicate  perforations  of  the  drum-membrane  were 
formerly  considered  very  rare  (for  instance  by  Polit- 
zer,  "  Beleuchtungsbilder,"  S.  135), 
but  from  what  I  have  seen  during  life, 
and  also  on  dissection,  double  and 
triple  perforations,  separated  from 
each  other  by  a  bridge  of  membrane, 
are  by  no  means  uncommon.  For  a 
long  time  I  doubted  the  existence  of  ""'g  ^i. 

the    cribriform  condition  of   the    mem-       Double  Perforation  of 

the  Drum-membrane. 

brana  tympani  such  as  was  first  de- 
scribed by  Bonnofont,  but  from  my  own  experience 
I  am  convinced  that,  not  only  in  tuberculosis  pulmo- 
num  and  miliary  tuberculosis,  but  also  in  scarlatina 
Avith  pharyngeal  diphtheritis  and  pytemic  conditions, 
the  membrana  tympani  may  be  simultaneously  per- 
forated at  different  points.  These  multiple  perfora- 
tions are  at  first  vQvy  minute,  but  rapidly  enlarge  and 
finally  coalesce  into  a  large  opening  (perhaps  from 
emboli).^ 

With  the  very  marked  regenerative  power  pos- 
sessed by  the  drum-membrane  ^  healing  of  perfora- 
tions is  very  frequently  observed.  Destruction  of 
more  than  two  thirds  of  the  whole  membrane  may 
be  restored.  In  recent  perforations,  and  in  those 
without  much  loss  of  substance,  the  healing    takes 

1  On  multiple  perforation  of  the  drum-membrane  compare  C.  E.  E. 
Hoffmann,  A.f.  0.,  iv.,  S,  277. 

^  I  once  saw  a  wonderful  instance  of  this  in  a  case  in  which  I  had  ex- 
cised more  than  two  thirds  of  the  drum-membrane  and  had  also  removed 
the  entire  hammer.  After  some  weeks  the  whole  opening  was  closed  by 
a  newly  formed  membrane. 


80  PATHOLOGY  OF   THE  EAR. 

place  without  leaving  any  visible  pathological  change 
on  the  membrane  ;  in  older  and  larger  perforations  a 
persistent  cicatrix  results.  The  drum-membrane  be- 
comes at  first  pale  and  dry,  the  edges  of  the  perfora- 
tion become  thin,  and  with  strong  illumination  ap- 
pear to  be  translucent,  and  closure  occurs  from  the 
growth  of  connective  tissue  from  the  edges. 

Not  infrequently  broad  bands  of  blood-vessels  are 
seen  running  from  the  edges  of  the  perforation  to- 
wards the  periphery  of  the  drum-membrane,  but 
after  the  closure  of  the  opening  these  gradually  dis- 
appear,  although   they  may   remain  visible    on    the 


Fig.  42.  Fig.  43. 

Fig.  42.     Oval  cicatrix  in  the  drum-membrane. 

Fig.  43.  Large  cicatrix  in  the  posterior  half  of  the  drum-membrane;  in  the  an- 
terior half  is  a  round  perforation  with  calcified  edges  and  two  calcified  spots.  (From 
Politzer,  "  Beleuchtungsbilder,"  etc.,  Taf.  II.,  Fig.  4.) 

newly  formed  cicatrix  for  a  long  time.  The  fully  de- 
veloped cicatrix  consists  of  a  thin  stratum  of  connec- 
tive tissue  containing  capillary  vessels,  and  each  side 
of  this  is  covered  by  a  very  thin  layer  of  epithelium. 
The  lamina  j^roj^ria  is  not  rejjrochiced,  but  is  seen  on 
the  edges  of  the  cicatrix  sharply  defined  and  passing 
directly  into  concentric  fibrillary  connective  tissue 
running  parallel  to  the  edges  of  the  cicatrix.  Some- 
times, in  certain  spots,  the  fibres  of  the  lamina  pro- 
pria pass  into  the  cicatricial  tissue  and  undergo  a 
change  of  form. 


THE  DRUM-MEMBRANE.  81 

The  cicatrix,  on  account  of  its  want  of  lamina  pro- 
pria, always  appears  to  lie  below  the  plane  of  the 
rest  of  the  drum  membrane,  i.  e.,  sunken  inwards 
nearer  the  wall  of  the  labyrinth. 

The  size  and  shape  of  cicatrices  vary  according  to 
the  original  loss  of  substance.  The  most  usual  form 
is  oval,  round,  or  kidney-shaped. 

By  inspection  from  the  meatus  they  appear  sharply 
defined,  darker  than  the  surrounding  tissue  and 
sunken  inwards.  On  the  inflation  of  air  into  the 
middle  ear  the  cicatrix  is  pressed  outwards  and  be- 
comes wrinkled.  Large  cicatrices  may  lie  against 
the  long  process  of  the  incus  or  against  the  labyrinth- 
wall  and  the  stapes  ;  they  may  be  attached  to  these 
parts  either  directly  or  by  bands  and  membranes  of 
connective  tissue. 


Fig.  44.  Fig.  45. 

Fig.  44.  Two  very  large  Cicatrices  in  the  Drum-membrane  before  and  behind  the 
Manubrium,  throughout  most  of  their  extent  adherent  to  the  labyrinth-wall  of  the 
tympanum. 

Fig.  45.  Funnel-shaped  retracted  Cicatrix  of  the  Drum-membrane  adherent  to  the 
Labyrinth- Wall.  (A  diagrammatic  section  through  the  meatus,  drum-membrane,  and 
tympanum;  from  Pol itzer,  "  Beleuchtungebilder,"  etc.,  S.  109.) 

When  the  cicatrix  adheres  directly  to  the  labyrinth- 
wall  a  cross-section  through  it  sometimes  shows  a 
cavity  resembling  a  cyst  or  glandular  involution  of 
the  surface.  The  origin  of  these  apparent  changes 
will  be  considered  in  the  chapter  on  the  tympanum. 


82  PATHOLOGY  OF   THE  EAR. 

The  external  surface  of  those  cicatrices  which  are 
attached  to  the  wall  of  the  labyrinth  are  generally 
moist  and  occasionally  secrete  pus,  owing  to  an  insuf- 
ficient hardening  of  the  epithelium.^ 

In  very  many  cases  this  desired  closure  of  the  per- 
foration by  cicatrix,  does  not  take  place,  but  the  ex- 
ternal and  internal  surfaces  of  the  edges  of  the  per- 
foration unite  and  the  opening  of  the  membrane 
becomes  permanent.  In  such  cases  there  may  be  a 
thickening  of  the  edges  of  the  perforation,  by  a  new 
growth  of  connective  tissue  (Fig.  36),  and  this  may 
undergo  calcification  (Fig.  43). 

An  apparent,  but  unreal  cicatrization  sometimes  oc- 
curs from  the  swollen  mucous  membrane  entirely 
filling  the  tympanum,  so  that  the  edges  of  the  perfo- 
ration lie  in  contact  with  and  become  adherent  to 
this  tympanic  mucous  membrane.  In  such  a  case  is 
seen  a  deeply  sunken  spot  on  the  membrana  tympani 
covered  with  thickened  epidermis. 

4.  Detachment  of  the  Manuhrium 
From  its  insertion  into  the  drum-membrane  gener- 
ally takes  place  only  at  its  lower  end,  seldom  through- 
out its  whole  length  ;  it  then  projects  into  the  tym- 
panum, and  approaches,  or  even  touches  the  prom- 
ontory ;  this  occurs  frequently  during  inflammatory 
softening  (hyperasmia  and  swelling)  of  the  membrana 
tympani  from  the  tension  of  the  tendon  of  the  tensor 
tympani,  and  is  found,  both  with  and  without  per- 
foration of  the  membrane  in  the  vicinity  of  the 
manubrium.  In  one  case  I  saw  such  a  detachment 
with  a  double  perforation  (Fig.  47).     On  the  mucous 

1  Politzer,  I.e.,  S.  111. 


THE  DRUM-MEMBRANE.  83 

membrane  opposite  the  detached  bone,  a  shallow 
groove  or  a  slight  eminence  is  sometimes  seen.  In 
other  cases  the  detached  manubrium  appears  to  lie  in 
its  usual  position  on  the  drum-membrane,  but  can  be 
very  easily  raised  from  it.  Wendt  once  found  a  de- 
tached and  separated  manubrium  embedded  in  a  tu- 
bular covering  of  bright  red,  soft,  smooth  tissue,  in 
which  the  bone  was  readily  movable.     After  detach- 


Fig.   46.  Fig.   47. 

Fig.  46.  Diagrammatic  Section  through  Meatus,  Drum-membrane,  and  Tympa- 
num, to  demonstrate  the  separation  of  the  manubrium  from  the  drum-membrane. 
(From  Politzer,   '"Beleuchtungsbilder,"  S.  118.) 

Fig.  47.  Double  Perforation  of  the  Membrane  with  a  Manubrium  detached,  and 
at  its  lower  end  atrophied.     Seen  from  the  tympanum. 

ment,  the  manubrium  may  again  be  united  to  the 
drum-membrane  by  a  bridge  of  connective  tissue. 
No  constant  change  in  the  curvature  of  the  mem- 
brana  tympani  is  produced  by  a  detachment  of  the 
manubrium ;  the  membrane  may  be  flattened  ex- 
ternally, or  it  may  appear  abnormally  concave,  or 
show  partial  projections,  especially  on  its  posterior 
upper  part.  On  inspection,  detachment  can  some- 
times be  diagnosticated  from  the  fact  that  the  manu- 
brium suddenly  disappears,  perhaps  just  below  the 
short  process,  and  yet  no  abnormal  concavity  of  the 
membrane  exists. 

According  to  Gruber  the  cartilaginous  covering  of 
the  manubrium  may  be  separated  from  the  bone  by 


84  PATHOLOGY  OF   THE  EAR. 

a  collection  of  fluid  between  the  two,  but  this  is 
doubtful. 

5.  Abscess. 
Interlamellar  abscesses  of  the  membrana  tympani 
may  occur  with  acute  myringitis  and  acute  catarrh 
of   the    tympanum,    but    are   rare ; 
when    present   they   are   generally 
multiple,  and  appear  as  slight  prom- 
inences of  a  yellow  color,  and  of  a 
dull,  waxy  lustre.    On  pressure  with 
a  probe,  a  depression  can  be  made 
in  them  as    seen  in  the   centre  of 
Interlamellar  Abscess  in  Fig.  48.  The  drum-mcmbrane  is  hy- 

the  Drum-membrane.  pgr^Emic  and  SWOllcU.        They  should 

not  be  confounded  with  the  much  more  common  par- 
tial projections  of  the  membrane,  produced  by  collec- 
tions of  secretion  within  the  tympanum. 

6.    Ulceration 

Seldom  comes  under  observation  on  account  of  the 
slight  thickness  of  the  drum-membrane  (0.1  mm.). 
It  may  be  confined  to  the  layer  of  the  cutis  in  myrin- 
gitis with  hypersemia  and  swelling,  or  to  the  mucous 
meml3rane  in  suppurative  inflammation  of  the  tym- 
panum, as  the  precursor  of  perforation,  or  it  may  oc- 
cur associated  with  perforations. 

When  in  the  cutis  it  ajDpears  as  a  shallow  depression, 
w4th  an  uneven,  rough,  villous,  dirty-red  base  which  is 
covered  with  discolored  detritus  or  crusts  of  dried  pus.^ 
The  rest  of  the  drum-membrane  is  softened  and  thick- 
ened by  the  inflammation. 

1  On  ulcerations  of  the  drum-membrane,  compare  Toynbee,  Diseases 
of  the  Ear,  p.  145.  Wilde,  Practical  Observations,  p.  271.  Politzer, 
Beleuchtumjshilder,  S.  66.     Von  Troeltscb,  Lelirhuch,  4  Aufl.  S.  119. 


THE  DRUM-MEMBRANE.  85 

7.  Anomalies  of  the  3Iemhrana  Flaccida  ShrapnelL 
Retraction  of  Shrapnel's  membrane  may  occur  with 
or  without  adhesion  to  the  neck  of  the  hammer,  the 
curvature  of  the  drum-membrane  remaining  normal, 
or  showing  increased  concavity :  it  is  also  common 
with  a  wrinkled  condition  or  with  perforation  of  the 
drum-membrane  (Fig.  40).  Since  Shrapnel's  mem- 
brane is  an  accessory  part  of  the  membrana  tym- 
pani  of  no  importance  for  the  functions  of  the  ear, 
its  pathological  changes  possess  but  little  interest.  It 
was  formerly  erroneously  thought  by  Zaufal  that  a 
funnel-shaped  retraction  of  this  membrane  w^as  path- 
ognomonic of  partial  anchylosis  of  the  hammer-incus 
articulation,  but  this  appearance  is  often  found  with 
a  perfectly  normal  condition  of  the  middle  ear. 

Atrophy  of  the  Drum-membrane,  partial  or  total,  is 
very  common.  The  Partial  Atroj^hy  is  caused  by 
disappearance  of  the  lamina  propria  from  circum- 
scribed affections  of  the  mucous  membrane  during 
chronic  tympanic  catarrh  without  perforation.  In 
appearance  it  is  sometimes  difSficult  to  distinguish  it 
from  cicatrices,  but  it  generally  shows  less  distinctly 
defined  edges  than  these  latter. 

Total  Atro2-)hy,  generally  of  the  membrana  pro- 
pria, is  very  common  from  long-continued  closure  of 
the  Eustachian  tube,  which  causes  increased  tension, 
and  so  a  tension-atrophy ;  it  is  sometimes  caused  by 
masses  of  cerumen  lying  against  the  membrane  (a 
pressure-atrophy).  The  formation  of  numerous  ra- 
diating, straight  or  curved  folds,  with  striated  reflec- 
tions of  light,  after  inflation  of  the  tympanum,  are 
characteristic   of  total  atrophy,   as  is    also  abnormal 


86  PATHOLOGY  OF   THE  EAR. 

mobility  of  the  membrane  under  variations  of  the  air- 
pressure. 

With  very  marked  atrophy,  the  membrana  tym- 
pani  sinks  into  the  tympanum  (collapse  of  Wilde),  and 
the  contour  of  the  labyrinthine  wall,  promontory, 
niche  of  the  fenestra  rotunda,  incus,  and  stapes,  may 
be  visible,  together  with  the  chorda  tympani  and  the 
pouches  of  Troeltsch.  If  hypergemia  of  the  labyrinth- 
wall  exists,  this  is  readily  recognized  by  the  trans- 
mission of  a  violet-red  color  through  the  atrophied 
membrane.  With  the  higher  degrees  of  atrophy  per- 
forations of  the  drum-membrane  may  occur  without 
a  preceding  suppuration  (p.  78). 

With  partial  atrophy  of  the  lamina  propria  there 
are  occasionally  hernial  protrusions  of  the  mucosa 
between  the  separated  fibres  of  the  membrane,  form- 
ing hladdei'  or  p^«rse-?^^e  j^i^^oininences  on  the  mem- 
brana tympani  which  contain  air  or  secretion.  With 
a  partial  loss  of  substance  in  the  mucosa  and  lamina 
propria  during  chronic  inflammation  of  the  tjan- 
panum,  it  may  happen  that  an  exten- 
sive emphysema  of  the  membrana 
tympani  is  produced  by  a  collection 
of  air  beneath  its  cutis  ;  this  is  par- 
ticularly likely  to  occur  from  infla- 
tion of  the  middle  ear.  AVith  this 
emphysema  the  membrana  tympani 

Purse-like  Projection  on    prCSCUtS    a    TOUgh     SUrfaCC,     and    tllC 

the  Drum-membrane.  manubrium  is  couccalcd.  Usually 
it  disappears  rapidly  when  the  air  pressure  ceases. 

New  Growths.  The  common  granulation-groioths 
have  been  described  already  (p.  74). 

Upithelial  growths  occur  both  on  the  skin  and  the 


Fig.  49. 


THE  DRUM-MEMBRANE.  87 

mucosa  of  the  drum-membrane.  They  are  seen  ex- 
ceptionally on  the  skm  in  the  form  of  circumscribed, 
hard,  glistening  white,  pearl-like  bodies,  varying  in 
size  from  a  millet  seed  to  the  head  of  a  pin,  and  are 
sometimes  found  in  large  numbers.  They  are  of  car- 
tilaginous consistence,  and  contain  a  yellowish  thick 
mass  (epithelium)  inclosed  in  a  firm  investing  mem- 
brane;  they  are  subject  to  an  excentric  change  of  po- 
sition with  the  growth  of  the  epithe- 
lial layer  of  the  drum-membrane^ 
just  as  extravasations  are.  Since 
glandular  elements  are  wanting  in 
the  membrana  tympani,  these  small 
tumors  cannot  be  regarded  as  mil- 
ium, which  they  externally  very  Fig.  so. 
closely  resemble,  but  may  be  possi-  J^^'^^  ^™^^"'^  ""/^^ 

^  '  J  L  Drum -membrane.     Irom 

bly  very  small  cholesteatomata.        Urbantsciutsch. 

The  epithelial  new  growths  on  the  mucous  mem- 
brane are  flat,  round,  white  protuberances,  only  vis- 
ible from  within  the  tympanum. 

Membranous,  papillary,  and  polypoid  new  growths 
are  very  common  on  the  mucosa.  All  the  transition 
forms  are  seen,  from  the  polypi  of  microscopic  size 
attached  to  the  mucosa  by  a  small  pedicle  to  com- 
plete polypoid  degeneration  of  the  whole  drum-mem- 
brane. Von  Troeltsch^  first  discovered  that  sometimes 
the  fibres  of  the  membrana  propria  were  to  be  found 
in  large  numbers  in  polypi  originating  from  the 
membrana  tympani. 

The  cholesteatoma  of  the  drum-membrane,  several 
cases  of  which  have  been  described,  was  once  exam- 

^  First  described  by  Urbantschitscb,  A.f.  O.,  x.,  S.  7. 
2  Virchoiv^s  Archiv,  xvii.,  S.  44. 


88  PATHOLOGY  OF   THE  EAR. 

ined  histologically  by  Wendt,  and  found  to  have  been 
developed  from  the  endothelial  sheaths  of  the  pro- 
cesses of  the  lamina  propria.  The  tumor  was  situated 
on  the  inner  surface  of  a  perforated  drum-membrane, 
was  hemispherical,  bright-red,  slightly  knobbed,  and 
with  a  bright  metallic  or  golden  lustre.  It  was  sur- 
rounded by  an  investing  membrane  of  connective 
tissue,  a  continuation  of  the  mucous  membrane  ;  and 
was  composed  of  '•  alternating  hypertrophied  pro- 
cesses and  sheaths  of  the  lamina  propria  arranged  con- 
centrically, the  latter  containing  a  deposit  of  choles- 
terine." 

In  the  case  described  by  Hinton^  (sebaceous  tu- 
mor), a  brownish  tumor,  the  size  of  a  pea,  consisting 
of  a  thin  sack  of  connective  tissue  (possibly  from  the 
membrana  tympani),  and  containing  laminae  of  epi- 
thelium, was  situated  on  the  inner  surface  of  the  drum- 
membrane,  above  the  processus  brevis ;  the  tumor 
was  directly  adherent  to  the  drum-membrane ;  there 
had  been  no  preceding  otorrhoea ;  the  tympanum  con- 
tained numerous  pseudo-membranous  bands. 

Tubercle  of  the  membrana  tympani  appears  in  chil- 
dren with  miliary  tuberculosis  as  yellowish-red  spots, 
as  large  or  larger  than  the  head  of  a  pin,  situated  in 
the  intermediar  zones  of  the  membrane  ;  the  remain- 
ing portions  of  the  membrane  are  without  injection, 
and  of  a  yellowish-gray  opacity,  from  the  transmission 
of  color  from  the  muco-purulent  exudation  within  the 
tympanum.  Examined  from  the  tympanum  these 
spots  appear  flat,  slightly  projecting  above  the  plane 
of  the  mucous  membrane,  and  clearly  defined.  In 
chronic  tuberculosis  of  the  lungs  in  adults,  I  have  fre- 

^  Compare  A.  f.  0.,  ii.,  S.  151. 


THE  DRUM-MEMBRANE. 


89 


qiiently  seen  during  life  yellowish,  slightly  prominent 
hard  spots,  which  were  followed  by  a  rapid  ulcerative 
destruction  of  the  niembrana  tympani,  and  which 
were  apparently  tubercles  of  that  membrane.  The 
histological  confirmation  of  this  opinion  is  at  present 
wanting. 

Rupture  of  the  Drum-membrane   frequently  occurs  di- 
rectly from  injury  (entrance  of  a  foreign  body),  or 


Fig.   53. 


Fig.  51.  Rupture  of  the  Drum-membrane,  from  a  blow  on  the  ear.  From  Toyn- 
bee,  "Diseases  of  the  Ear,"  p.  182. 

Fig.  52.  Rupture  of  an  atrophied  Drum-membrane,  from  violent  inflation  by 
Yalsal-a's  method.     From  Toynbee,  Ibid.,  p.  ]83. 

Fig.  53.  Rupture  of  the  Drum-membrane,  from  a  person  who  was  hanged.  Seen 
from  the  tympanum. 


indirectly  from  air  pressure  (explosion,  box  on  the 
ear,  diving,  and  from  whooping  cough) ;  also,  from 
fractures  of  the  skull,  and  from  violent  concus- 
sions of  the  petrous  bone.  The  edges  of  a  rupture 
from  a  direct  wound  are  generally  irregular,  jagged, 
and  suffused  with  blood ;  those  of  a  rupture  from  in- 
direct force  almost  always  show  a  clean  fissure  parallel 


90  PATHOLOGY  OF   THE  EAR. 

to  the  radial  fibres  of  the  membrane.  The  ruptures 
which  are  seen  in  artillerists  often  run  parallel  to  and 
behind  the  manubrium.  When  ruptures  occur  from 
a  moderate  air-pressure,  it  will  usually  be  found  that 
the  anatomical  condition  of  the  drum-membrane  pre- 
disposed thereto,  atrophy  or  calcification  having  ex- 
isted previously. 

Simple  ruptures,  without  deeper  injury  of  the  ear, 
usually  heal  in  healthy  individuals  and  under  proper 
care  in  from  a  few  days  to  a  few  weeks,  sometimes 
leaving  a  cicatrix  and  sometimes  not. 

Simultaneously    with    rupture    of 

EHHJI  the   drum-membrane,  in   rare   cases, 
*  !■  ^^^^^^^  dislocation  of  the  hammer  and 
!(      Il  incus,   and   in   still  more   rare   cases 
H  fractures  of  the  manubrium.     These 
^hH  fractures  of  the  bone  may  heal,  leav- 
^^^   ing  very  marked  changes  in  its  form, 
'^    '^'  such  as  abnormally  oblique  position. 

Fractured  Manubrium,    contortiou   of  itS    loUS^    axis,  Or  aUgU- 
From   Roosa,    "Diseases  ,    .  p     i        i  p 

of  the  Ear,"  1873,  p.  236.  lar  positiou  of  the  lowcr  fragment. 


THE    TYMPANUM. 

According  to  our  present  pathologico-anatomical  knowledge,  the 
tympanum  is  the  most  frequently  involved  in  pathological  processes 
of  all  the  parts  of  the  ear.  The  mucous-periosteal  covering  of  this 
cavity  is,  in  its  normal  condition,  extremely  thin  and  delicate,  being 
only  0.75  mm.  thick  ;  it  is  perfectly  translucent,  colorless,  and  glis- 
tening fi'om  slight  moisture ;  it  covers,  in  addition  to  the  walls  of 
the  cavity,  all  the  ossicles,  and  the  tendons  of  the  musculus  tensor 
tympani  and  musculus  stapedius.  The  air  cavity,  inclosed  by  this 
mucous  membrane,  has  the  physiological  function  of  furnishing  a 
free  space  for  the  vibrations  of  the  membrana  tympani  and  the  ossi- 
cles, and  for  the  distention  of  the  membrane  of  the  fenestra  rotunda. 


THE    TYMPANUM.  Ql 

Any  changes  within  this  space,  which  can  produce  any  obstruction 
to  the  free  vibration  of  these  parts  must  be  the  cause  of  disturbances 
of  hearing.  The  most  common  of  these  changes  are  large  collec- 
tions of  secretion,^  swelling  and  rigidity  of  the  mucous  membrane 
with  the  consequent  diminished  mobility  of  the  conducting  appara- 
tus, destructive  processes  from  ulceration,  abnormal  adhesions  of 
parts  of  the  conducting  apparatus  with  each  other,  or  with  the  walls 
of  the  cavity,  and  tumors. 

Pathologically,  the  mucous  periosteal  covering  of  the  tympanum 
has  many  of  the  properties  of  the  serous  membranes,  although, 
according  to  its  histological  structure  and  its  development,  it  must 
be  considered  a  mucous  rather  than  a  serous  membrane.  Its  arterial 
blood  is  obtained  from  several  sources :  the  arteria  meningea  media, 
a  branch  of  the  maxillaris  internus  ;  arteria  stylomastoidea  and  pha- 
ryugea  ascendens,  branches  of  the  carotis  externa ;  arteria  auricularis 
posterior ;  arteria  tympanica ;  and  arteria  carotis  interna ;  all  of 
which  anastomose  with  each  other. 

The  veins  pass  internally  through  fine  openings  of  the  fissura 
petroso-squamosa  to  the  veins  of  the  dura  mater,  and  thence  into 
the  sinus  petrosus  superior,  and  also  externally  to  the  venous  ring 
surrounding  the  drum-membrane,  and  to  the  meatus.  According  to 
Kessel,  the  lymph-vessels  form  here  and  there  a  tubular  system  in 
the  periosteum,  which  is  provided  with  oval  expansions  or  lateral 
projections.  Under  the  tegmen  tympani,  where  the  periosteum  sep- 
arates from  the  mucous  membrane,  are  funnel-shaped  or  round 
lymph  spaces  communicating  with  each  other  and  with  a  fine  net- 
work of  vessels.  From  the  variation  of  air-pressure  in  the  tympa- 
num, the  movement  of  the  lymph  in  these  lymph-spaces,  and  the 
system  of  tubes  is  caused  (Kessel). 

The  connective  tissue  of  the  tympanic  mucous  membrane  can  be 
divided  into  a  subepithelial  and  a  periosteal  layer.  The  latter  gives 
off  fibres  to  the  tunica  adventitia  of  the  blood-vessels  of  the  bone, 
and  to  the  sheaths  of  the  nerves  which  pass  along  the  grooves  of 
the  bone,  and  on  this  account  and  on  account  of  the  arrangement 
of  the  blood-vessels,  it  can  be  designated  as  the  periosteum  (Prus- 
sak). 

Peculiar  bodies,  with  the  structure  of  the  Pacinian  tactile-cor- 
puscles, were  simultaneously  described  by  Kessel  and  Politzer  as 

1  A  few  drops  of  serous  fluid  are  very  often  found  in  the  tympanum, 
■with  an  otherwise  normal  condition  of  the  ear. 


92  PATHOLOGY  OF   THE  EAR. 

normal  attributes  of  the  mucous  membrane  of  the  tympanum  and 
mastoid  process ;  by  the  former  they  were  regarded  as  organs  of 
special  physiological  imiDortance ;  but  later,  Wendt^  showed  that 
they  were  artificial  products,  atrophic  remains  of  pseudo-membranes. 
Von  Troeltsch' found  similar  bodies  in  1859,^  and  described  them  as 
pathological  formations  ;  and  some  observers  still  consider  them  as 
such ;  for  instance,  Zaufal,  who  considers  them  psaumomata. 

For  microscopical  investigation,  the  tympanic  mucous  membrane 
must  be  separated  from  the  bone,  which  can  be  most  easily  done  on 
the  labyrinthine  wall.  It  must  then,  for  the  preparation  of  cross 
sections,  be  hardened  for  some  days  in  dilute  chromic  acid,  then  em- 
bedded in  liver  which  has  been  hardened  in  alcohol,  or  in  supporting 
liquids,  as  mucilage,  or  glue  and  glycerine. 

Malformations.  The  tympanum  may  be  replaced 
by  a  solid  mass  of  bone.  Sometimes  it  is  onl}-  rudi- 
mentary, sometimes,  on  the  contrary,  it  is  enormously 
large.  Again,  the  labyrinthine  fenestr^e  may  be  want- 
ing, entirely  or  partially.  Slight  changes  from  the 
normal  formation  of  the  walls  are  common ;  namely, 
absence  of  the  eminentia  pyramidalis,  osseous  nar- 
rowing of  the  labyrinthine  fenestra3,  protrusion  of  the 
lower  wall  with  obliteration  of  the  fenestra  rotunda 
(Odenius). 

The  ossicles,  all  ^  or  any  of  them,  may  be  congen- 
itally  wanting.  A  fusing  of  the  three  ossicles  into  one 
(columella)  has  been  found.^  Michael  Jaeger  found 
a  stapes  with  only  one  crus  fused  Avith  the  incus. 
Sometimes  superfluous  ossicles  are  present.  A  long 
cylindrical  sesamoid  bone  between   the  malleus  and 

1  According  to  W.  Krause,  they  consist  of  concentric  layers  of  connec- 
tive tissue,  ■without  nerve-fibres  and  -witliout  interstitial  fluid. 

-  Virchow^s  Archil;  xvii..  S.  60. 

3  Otto,  Lehrhuch  der  Patholorj.  Anatomic,  Berlin,  1830,  Bd.  i..  S.  172. 
Bernard.  Treviranus,  Itard. 

■*  Constatts'  JaJiresbericht,  184  7,  Heidenreich,  S.  111. 


THE    TYMPANUM.  93 

incus  was  found  in  the  case  of  Rose  ^  with  atresia  of 
the  meatus,  also  in  the  case  of  Otto.^ 

Malformations  in  the  shape  of  the  ossicles,  espe- 
cially of  the  stapes,  where  they  are  abnormally  small 
or  large,  are  more  common.  In 
the  stapes  we  may  have  an  un-  ^^ ^^^==^ 
equal  leno^th  of  its  crura,  or  only  ^""^ 

i  °  ,  .^         "^  ""ig-   ".  Fig.   56. 

one  crus  may  be  present  (Com- 

.  1      ,  rr,.     1  ^^^-  55-     T'^*^  Stapes  (s)  has 

parettl,    CaSSebohrn,    Tiedemann,    its  normal  base,  but  only  one 

MichaelJaeger),oronecrusmay  T"''  '''"'"'  ^Th  '"'"  ''1 

CI       /'  'J     long    process    of    the    normal 

not  reach  the  base,  or  both  crura  i"cus  (i\  one  bone,   on  the 

1  -ill  1-1  r-    Hammer  [m],  the  manubrium 

may    be     united     by    a    bridge     of    and  short  process  are  wanting. 

bone,     this     latter     malformation,    '^''^'^  drum-membrane  was  also 

.  wanting.     (From  M.  Jaeger.) 

aCCOrdmg     to      Bonnafont,     bemg       Fig.  56.      Malformation    of 

quite    common.     The   loner   arm  *'^^^'T^' ""^^' '^"^^T 

^  ^  O  reach  the  base.    (From  \V  elck- 

Of  the   incus  may  be  more  or  less    er,   "  Archiv  flir  Ohrenheilk.," 

bent.  Ba.i.,™.,i.,ri«.3, 

The  rarest  congenital  malformations  of  shape  are 
in  the  malleus,  Bonnafont^  quotes  one  observation 
of  congenital  absence  of  the  manubrium  in  a  calf. 
Michael  Jaes-er  found  in  one  case  of  cono:enital  ab- 
sence  of  the  membrana  tympani  and  meatus  that  the 
head  and  neck  of  the  malleus  were  of  regular  shape 
and  in  normal  connection  with  the  incus,  but  that  the 
manubrium  and  processus  brevis  were  wanting. 

Hypersemia  and  Hemorrhage.  Hyperemia  of  the 
tympanic  mucous  membrane  in  its  different  degrees 
is  among  the  most  common  occurrences.  Especially 
in  childhood  it  may  easily  occur  with  every  cold  in 
the  head,  bronchitis,  stomatitis  aphthosa,  or  angina, 

1  Rose,  vide  A.  f.  0.,  iii.,  S.  251. 

2  Otto,  L  c,  S.  174,  note  21. 

3  l.  c,  p.  538. 


94  PATHOLOGY  OF   THE  EAR. 

and  may  disappear  again  in  a  short  time  without 
leaving  any  anatomical  or  functional  disturbances. 
Yenous  congestion  may  take  place  with  disease  of 
the  heart  or  lungs,  or  with  tumors  of  the  neck,  which 
exert  a  pressure  on  the  veins  of  the  neck.  It  may 
also  occur  secondarily  from  suppuration  of  the  inner 
ear,  and  from  meningitis  by  extension  along  the  pro- 
cesses of  the  dura  mater  which  pass  into  the  tj'm- 
panum. 

The  hyperemia  affects  by  preference  the  venous 
vessels,  which  become  not  only  enlarged  but  tortu- 
ous and  with  occasional  expansions.^ 

Isolated  small  ecchymoses  are  often  found  with  re- 
cent hypersemia  of  the  mucous  membrane. 

Extravasations  of  blood  into  the  tympanum  (h^em- 
ato-tympanum)  occur  through  injury  from  severe 
concussion  of  the  skull  (blow,  fall  on  the  head)  with 
or  without  fracture  of  the  temporal  bone  ;  ^  through 
direct  injury  of  the  ear  by  the  entrance  of  sharp 
substances  with  simultaneous  rupture  of  the  drum- 
membrane  ;  through  strangulation,  violent  vomiting 
and  whooping  cough.  They  may  also  occur  spon- 
taneously with  acute  inflammations,  with  morbus 
Brightii,  cynanche  diphtheritica,  and,  according  to 
Trautmann,  with  endocarditis  verrucosa  recens  and 
ulcerosa.  The  extravasation  which  appears  through 
the  drum-membrane  of  bluish-red  or  bluish-black 
color,  may  be  resorbed  or  may  lead  to  suppurative 
inflammation. 

1  Politzer,  A.  f.  0.,  vii.,  S.  13. 

2  A  case  of  haeniatotympanum  without  injury  of  the  drum-membrane, 
meatus  or  pars  petrosa,  from  a  fatal  blow  with  an  axe,  is  desci'ibed  by 
Casper,  Handbuch  der  Gerichtlichen  Medecin,  Thanatalog.  TheiL,  S.  209, 
Fall  66. 


THE   TYMPANUM.  95 

Hemorrhagic  infiltrations  of  the  mucous  membrane 
occur  with  congestive  catarrhs  of  the  middle  ear. 

Catarrhal  inflammation  is  characterized  by  hypera^mia, 
swelling,  and  exudation.  Although  in  most  cases  the 
exudation  is  of  a  mixed  character,  still  from  anatom- 
ical investigation  we  are  justified  in  distinguishing 
(1)  serous  catarrh,  (2)  mucous  catarrh,  (3)  purulent 
catarrh. 

These  three  forms,  pure  and  clearly  defined,  may 
occur  in  the  tympanum,  but  the  transition  forms  are 
much  more  common.  To  distinguish  them,  however, 
by  special  names,  according  to  the  character  of  the 
exudation,  would  be  scarcely  possible  and  practically 
valueless,  for  it  would  be  necessary  to  make  a  large 
number  of  subdivisions,  as  sero-mucous,  sero-hemor- 
rhagic,  muco-purulent,  muco-hemorrhagic,  etc. 

The  division  into  catarrhal  and  purulent  otitis  me- 
dia, favored  by  the  older  authors^  and. still  very  com- 
monly used,  is  not  defensible  because  the  first  variety 
can  pass  into  the  second  and  no  distinct  boundary  ex- 
ists between  the  two.  Perforation  of  the  membrana 
tympani  even  is  not  an  infallible  mark  of  distinc- 
tion. 

The  very  highest  degrees  of  catarrhal  swelling  of 
the  tympanic  mucous  membrane  are  capable  of  com- 
plete retrogression,  the  membrane  resuming  its  cob- 
web-like delicacy,  and  moulding  itself  accurately  to 
the  osseous  Avails  and  contents  of  the  tympanic  cav- 
ity. The  cellular  infiltration  of  the  subepithelial  con- 
nective tissue  disappears  by  fatty  degeneration  and 
decay,  and  possibly,  in  part,  by  being  absorbed  into 
the  lymph-vessels.     For  this  process  weeks  are  nec- 

1  Schlegtendal,  De  Otitide.  Diss.  Inaug.,  Halle,  1821. 


96  PATHOLOGY  .OF   THE  EAR. 

essary.  In  many  cases,  however,  retrogression  is  in- 
complete, and  there  remain  projections  and  duphca- 
tures  of  the  mucous  membrane  in  the  form  of  pseudo- 
membranes  or  synechice,  by  which  different  parts  of 
the  ear  are  abnormally  adherent  or  the  tympanic 
cavity  is  permanently  affected  in  its  size  and  form. 

The  serous  catarrh^  (otitis  media  serosa,  inflam- 
matory dropsy  of  the  tympanum)  is  the  least  com- 
mon of  the  three  varieties  and  should  not  be  mis- 
taken for  the  very  common  simple  transudation  (hy- 
drops ex-vacuo),  which  results  from  closure  of  the 
Eustachian  tube.  In  its  acute  form  the  membrana 
tympani  at  first  appears  reddened  by  a  fine  injection 
of  its  cutis  layer,  the  tympanic  mucous  memljrane 
throughout,  even  to  the  covering  of  the  ossicles,  is 
finely  injected,  and  the  cavity  is  in  part,  seldom 
wholly,  filled  Avith  a  clear,  yellowish  serous  fluid 
which  may  become  yellowish  red  from  the  intermix- 
ture of  blood  (sero-hemorrhagic).  A  slight  swelling 
of  the  mucous  membrane  is  sometimes  caused  by  a 
watery  infiltration,  oedema,  of  the  subepithelial  con- 
nective tissue.  The  Eustachian  tube  may  retain  its 
normal  permeability. 

If  the  membrana  tympani  has  not  been  rendered 
untranslucent  from  old  opacities,  it  is  possible  both 
during  life  and  after  death  to  recognize  the  boundary 
line  of  the  serous  exudation,  and  its  movement  on  a 
change  of  position  of  the  tympanum.  Sometimes, 
also,  bubbles  are  distinctly  visible. 

In  the  chronic  form  of  serous   catarrh  all  hypene- 

1  Scliwartze,  Paracentese  des  Trommel  fells,  Halle,  1808.  Politzer, 
A.  f.  0.,  iii.,  328.  Zaufal,  .1.  /.  0.,  v.,  S.  38.  Wendt,  Archiv.  fur 
Heilkunde  von  E.  Wagner,  xiii.,  S.  158-161. 


THE    TYMPANUM.  97 

mia  is  wanting,  but  hypertrophic  processes  are  com- 
mon in  the  mucous  membrane,  in  which  the  ossicles 
may  be  embedded  or  a  new  growth  of  membranes  or 
bands  (synechiaB)  be  produced. 

The  serous  catarrh  is  found  especially  common  in 
old  age  in  persons  otherwise 
•  healthy ;  it  is  also  found  with 
syphilis,  heart  diseases,  pneumo- 
nia, pleuritic  exudations,  Bright's 
disease,  naso-pharyngeal  catarrh, 
and  apparently  may  be  sometimes 
dependent  on  disturbances  of  vaso-  ^.    ^^ 

motor  innervation.  Serous   Exudation   in   the 

The      mucous       catarrh  ^      (otitis     Tympanum,  the  nearly  hor- 

izontal  boundary  line  of  the 

media  catarrhahs).  The  acute  liquid  appearing  through  the 
form  shows  a  universal  hypergemia  •^"""-"lembrane. 
of  varia])le  degree,  sometimes  with  hemorrhages  in 
the  subepithelial  connective  tissue,  and  swelling  of 
the  mucous  membrane.  This  swelling  may  affect  the 
whole  membrane  equally,  or  it  may  be  more  strongly 
marked  at  certain  spots,  the  tegmen  and  promontory ; 
it  is  produced  by  enlargement  of  the  blood-vessels 
and  hemorrhages,  which  press  the  fibres  of  connec- 
tive tissue  apart,  and  by  a  serous  and  cellular  infil- 
tration of  the  layer  of  loose  connective  tissue  beneath 
the  epithelium,  numerous  cells  like  lymph  corpuscles 
being   deposited  between   the  fibres. 

All  of  these  changes  are  confined  to  the  subepithe- 

1  Otto,  Seltene  Beohachtimgen  zur  Anatomie,  etc.,  I.  Heft,  Breslau,  1816, 
S.  111.  Duverney,  Traite  de  FOrgane  de  VOuie,  Paris,  1683,  Partiii., 
S.  184.  Ulricli,  Ueber  den  Catarrh  des  Mittleren  Ohres  (Oesterreich.  Jahr- 
hlicher,  1847,  October,  November,  and  December).  LehrbiicJier  Von 
Ptau,  Yon  Troeltsch,  Gruber,  etc.  Histologically  the  most  important  are 
the  articles  by  Wendt  in  Wagner's  Archiv. 


98  PATHOLOGY  OF   THE   EAR. 

lial  layer  of  connective  tissue.  The  epithelium  itself 
is  retained.  The  cavity  is  partially  or  wholly  filled 
with  thick  adhesive  mucus  mingled  with  a  few  cell 
elements,  epithelium,  mucous  or  pus  corpuscles,  red 
blood-corpuscles,  nucleated  cells  and  collections  of 
nuclei ;  not  infrequentl}^  in  the  dead  body  crystals, 
triiDle-phosphate  and  others,  are  found.  Gruber^ 
claims  to  have  also  found  goblet-cells  in  the  exuda- 
tion accompanying  mucous  catarrh  of  the  middle  ear. 
The  consistence  of  the  mucus  may  be  such  as  to 
require  a  regular  dissection  with  forceps  and  knife  in 
order  to  free  the  walls  and  the  ossicles.  It  may  be 
either  transparent  or  opaque  (white-gray,  bloody). 
If  the  whole  cavity  is  not  filled,  the  mucus  adheres 
by  preference  to  the  floor  and  to  the  niches  of  the 
labj'rinthine  fenestra?,  to  the  roof  of  the  cavity  on 
and  above  the  hammer-anvil  articulation,  and  on  the 
inner  surface  of  the  membrana  tympani.  In  the  lat- 
ter case  the  curved  boundary  lines  of  the  exudation 
may  be  visible  externally  through  the  drum-mem- 
brane. 

The  source  of  the  mucus  is  a  hypersecretion  of 
the  tubular  and  racemose  glands  existing  in  the  iyvn- 
panic  mucous  membrane,  which  are  found  enlarged 
and  widened  into  cysts  near  their  orifices  ;  ^  a  part 
of  the  mucus  also  comes  from  the  surfiice  of  the 
wdiole   mucous  membrane. 

The  chronic  variety  of  mucous  catarrh  leads  to 
thickening  of  the  mucous  membrane,  which  then  as- 

1  Lehrhuch,  S.  436. 

2  The  round  (jlandular  cysts,  ascribed  by  C.  Krause  to  tlie  normal  mu- 
cous membrane,  are  really  joatliological  enlargements  of  the  normal  tubu- 
lar slands. 


THE    TYMPANUM.  99 

Slimes  a  darker,  bluish-gray  or  white  appearance,  and 
seems  firmer,  stronger,  and  more  vascular  than  nor- 
mal ;  the  blood-vessels  also  become  varicose.  Some- 
times villous  prolongations  and  slight  elevations  are 
seen  on  the  surface  of  the  membrane.  The  thicken- 
ing may  be  confined  to  certain  spots,  the  mucosa  of 
the  drum-membrane,  malleo-incal  articulation,  laby- 
rinthine fenestrge,  or  it  may  be  equally  distributed 
over  all  portions  of  the  membrane,  and  may  even 
completely  obliterate  the  whole  tympanic  cavity. 
With  the  thickening  of  the  mucous  membrane  the 
membrana  tympani  appears  thickened,  leather}^,  and 
but  slightly  yielding  to  the  touch. 

In  its  clinical  history  the  mucous,  like  the  serous 
catarrh,  is  distinguished  from  the  purulent  catarrh  in 
that  it  does  not  usually  lead  to  ulcerative  destruction 
of  the  drum-membrane.  Occasionally,  to  be  sure,  it 
leads  to  slight  ruptures  of  a  drum-membrane  some- 
what softened  by  inflammation,  but  after  the  evacua- 
tion of  some  mucus  from  the  tympanum,  these  rup- 
tures soon  heal  and  have  no  influence  on  the  further 
course  of  the  disease.  Where  ulcerative  destruction 
occurs  we  are  no  longer  dealing  with  a  simple  mucous 
catarrh,  but  with  a  combination  of  the  mucous  with 
the  purulent  catarrh. 

Marked  thickening  from  a  new  growth  of  connec- 
tive tissue  on  the  fenestra  of  the  labyrinth,  and 
around  the  articulation  of  the  malleus  and  incus  are 
specially  injurious  to  the  conduction  of  sound.  The 
niche  of  the  fenestra  rotunda  may  be  completely 
closed  and  the  ossicles  may  be  wholly  embedded  in 
the  hypertrophied  mucous  membrane,  so  that  careful 
preparation  is  necessary  to  render  them  visible. 


100  PATHOLOGY  OF   THE  EAR. 

The  acute  mucous  catarrh,  loithout  i^erforation  of 
the  drum-7nemhrane,  may  unexpectedly  and  rapidly 
lead,  in  extremely  rare  cases,  to  sopor,  convulsions, 
and  death,  from  meningitis  (two  cases  of  my  own,, 
two  of  Wendt's).^  In  one  of  the  cases  described  by 
Wendt,  the  autopsy  showed  extensive  meningitis 
with  abundant  adherent  exudation  over  the  whole 
surfiice  of  the  brain. 

The  2^urulent  catarrh  (otitis  media  purulenta)  usu- 
ally leads  to  rupture,  ulceration,  and  loss  of  substance 
in  the  drum-membrane,  and  the  discharge  of  the  pus 
externally. 

An  exception  to  this  rule  is  only  found  in  the  forms 
of  the  disease  seen  in  nursing  children,  and  in  those 
cases  in  which  there  is  thickening  of  the  membrana 
tj^mpani.^ 

A  discharge  of  the  pus  towards  the  pharynx  through 
the  Eustachian  tube  is  unusual. 

The  acute  variety  is  very  common  with  the  acute 
exanthemata,  typhus,  tuberculosis  of  the  lungs,  and 
scrofula. 

The  exudation  may  be  pure  pus,  of  a  yellowish  or 
3^ellowish  green  color  and  creamy  consistency,  or  it 

1  ArcJtio  fur  Heilkunde  von  Wagner,  xi.,  Fall  12  u.  13. 

2  Literature  of  Otitis  Int.  Purulenta  Infantum  :  Duverney,  Tractatus 
de  Organo  Auditus,  NUrnberg,  1684,  S,  36.  Koppen,  Diss.  Inaug.,  1857, 
Marburg.  Von  Troeltsch,  Verhandlu7igen  der  Physihal.  Geselhclwji  in 
Wurzburg,  ix.,  1859.     See  also  LeJirbuch,  6  Aufl.,  S.  404.    Schwartze,  A. 

f.  0.,  i.,  S.  202-205,  1864.  Wreden,  M.  f.  O.,  1868,  No.  7,  et  seq. 
Brunner,  Beitrdge  zur  Anatomie  des  Mitderen  Ohres,  Leipzig,  1870,  S.  31. 
Zaufal,  Sectionen  des  Gehororgans  von  Neugeiorenen  und  Sduglingen, 
Oesterr.  Jahrh.  f.  Padiatrik,  1870,  1.,  S.  118  et  seq.  Wendt,  Ueber  das 
VerJialten  der  PaukenlwMe  beim  Fotus  und  Neugeborenen,  Arch,  der  Heil- 
kunde, xiv.,  1873.  Kutscbarianz,  A.  f.  0.,  x.,  S.  118-127,  1874,  Ed. 
Hofmann,  vide^.  /.  0.,  xi.,  S.  81,  1875. 


THE   TYMPANUM.  101 

may  contain,  in  addition  to  innumerable  pus  cells, 
granular  corpuscles,  and  granules,  a  small  amount  of 
epithelium  and  detritus,  with  some  mucus  or  blood 
(muco-purulent  catarrh).  Beneath  the  layer  of  pus 
the  mucous  membrane  is  bright  red,  deprived  of  its 
epithelium,  and  more  or  less  swollen,  even  to  a  thick- 
ness of  one  to  two  millimeters  or  more.  The  greatest 
swelling  usually  appears  on  the  roof  of  the  cavity  and 
on  the   promontory. 

The  swelling  is  due  to  enlargement  of  the  blood- 
vessels, cellular  and  serous  infiltration  of  the  connec- 
tive-tissue stroma,  and  sometimes  to  hemorrhagic 
infiltration. 

In  chronic  cases,  the  disease  leads  to  hyperplastic 
processes  in  the  mucous  membrane,  to  the  formation 
of  nodules,  villous  projections,  papillary  growths, 
knobbed  swellings,  or  polypoid  tumors.  Only  rarely 
does  the  hyperplasia  of  the  mucous  membrane  fill  the 
entire  cavity.  The  minute  granulations  on  the  surface 
of  the  mucosa,  which  are  composed  of  lymph-cells, 
generally  contain  loops  of  blood-vessels.  In  the  mid- 
dle layer  of  the  mucosa  there  is  a  thick  infiltration 
of  round  cells  gradually  disappearing  towards  the 
deeper  tissues.  In  the  periosteal  connective  tissue, 
which  is  the  most  rarely  affected  of  all  the  tissues, 
Politzer  ^  found  an  enlargement  of  the  lymph- vessels, 
and  near  by  round  or  oval  microscopic  cysts,  with  a 
connective  tissue  capsule  and  cellular  contents.  The 
cysts  varied  in  size  from  oV  to  \  mm.,  and  he  consid- 
ered them  to  be  loops  of  an  enlarged  and  varicose 
lymph-vessel. 

Secondary  ulceration  in  this  disease  is  relatively 
1  A.  f.  0.,  xi. 


102  PATHOLOGY  OF   THE  EAR. 

rare.  However,  from  a  deep  loss  of  substance  in  the 
mucous  membrane,  during  putrid  purulent  inflamma- 
tion, caries  may  occur  on  the  ossicula  or  the  walls  of 
the  tympanum.  If  the  pus  is  stagnant  for  a  long 
time,  fatty  pus  cells,  fatty  detritus  and  cholesterine 
are  found  ;  the  latter  particularly  under  the  tegmen 
tympani,  where  it  collects  in  large  adherent  layers  ; 
in  addition  to  these,  sometimes  epithelial  cells,  in 
white  laminated  crusts,  one  half  mm.  or  more  thick, 
are  seen.  From  the  stagnation,  drying  and  degener- 
ation of  the  purulent  masses  in  the  antrum  mastoi- 
deum,  fatal  resorption  and  infection  may  take  place 
(acute  miliary  tuberculosis,  tuberculous  self-infec- 
tion). 

With  chronic  suppuration  of  the  tympanum,  the 
dura  mater  over  the  tegmen  tympani  is  frequently 
diseased,  being  either  thickened  by  the  inflammation 
and  abnormally  adherent,  or  else  loosened  and  occa- 
sionally dotted  with  small  masses  of  pus. 

After  the  healing  of  a  chronic  suppuration  of  the 
tympanum,  the  perforation  of  the  drum-membrane 
remaining  open,  it  will  frequently  be  seen  that  the 
epidermis  of  the  meatus  has  extended  into  the  tym- 
panum, sometimes  even  into  the  mastoid  cells.  This 
dermoid  transformation  of  the  tympanic  mucous  mem- 
brane which  would  without  such  a  change  be  exposed 
to  many  injurious  influences,  affords  the  surest  pro- 
tection against  a  recurrence  of  the  suppuration,  and 
is  therefore  especially  desirable  in  all  cases  where  the 
defect  of  the  drum-membrane  is  such  that  its  closure 
by  cicatricial  tissue  cannot  be  expected. 

Partial  calcification  of  the  mucous  membrane,  affect- 
ing all  of  its  layers  and  projecting  above  the  normal 


THE    TYMPANUM.  103 

plane  of  the  membrane,  is  an  occasional  result  of 
clironic  tympanic  suppuration.  Such  calcifications 
of  the  mucous  membrane  are  sometimes  seen  during 
life  on  the  promontory,  if  there  is  a  favorably  situated 
perforation  of  the  drum-membrane.  Fine  blood-ves- 
sels sometimes  run  over  the  spots  of  calcification, 
showing  that  a  thin  layer  of  connective  tissue  remains 
upon  them. 

Purulent  tympanic  catarrh  may  be  fatal,  even  in 
adults,  without  there  being  an  externally  appreciahle 
disease  of  the  hone,  by  purulent  meningitis,^  or  phle- 
bitis of  the  sinuses  and  pyemia  ;^  this  may  occur 
without  perforation  of  the  drum-membrane.^  It  is 
less  common  in  the  acute  than  in  the  chronic  form  of 
the  disease.  As  a  rule  it  only  occurs  when  the  drum- 
membrane  has  been  increased  in  thickness  and  power 
of  resistance  by  previous  inflammatory  processes. 

Croupous  and  Diphtheritic  Inflammation.  The  exist- 
ence of  croupous  tympanic  inflammation  was  unknown 
till  it  was  very  recently  described  by  Wendt.  In 
most  cases  of  pharyngeal  and  lar3aigeal  croup  there 
is  only  a  collateral  hyperemia  or  catarrh,  either  mu- 
cous or  purulent,  in  the  ear ;  but  in  several  cases 
Wendt*  found  a  firm  croup-membrane  on  the  tym- 
panic mucous  membrane,  which  was  swollen,  much 
infiltrated  with  cells  and  hyperiemic.^  The  croup- 
membrane  also  covered  the  ossicula. 

1  Schwartze,  A.  f.  0.,  i.,  S.  200;  iv.,  S.  235,  Fall  1. 

2  Gruber,  Wiener  WochenUatt,  1862,  24,  25. 

3  Von  Troeltsch,  Anatomk  cles  Ohres,  S.  70.  Schwartze,  A.  f.  O., 
i.,  S.  200,  ii.,  S.  287,  iv.,  S.  235.  ]\Iayer,  Ihkl,  i.,  S.  226.  Pagenstecber, 
Arch.  f.  KUn.  Chir.,  iv.,  S.  531. 

^  Archiv  filr  Heilkunde,  x'ni.,  S.  157. 

^  Illustrated  in  A'Ins  der  Patholog.  Histologie  von  A.  Tliiei-felder,  i.  Lie- 
feriin2j.  Table  i.,  Figs.  5-7. 


104  PATHOLOGY  OF   THE  EAR. 

With  diphtheritic  inflammation  of  the  mucous  mem- 
brane of  the  nose  and  pharynx,  Schwartze  ^  and 
Wendt^  found  only  purulent  and  putrid  catarrh  in 
the  middle  ear;  Wreden,^  on  the  contrary,  reports 
that,  in  St.  Petersburg,  he  has  frequently  observed, 
during  life,  a  diphtheritic  inflammation  of  the  middle 
ear  in  the  course  of  scarlet  fever  with  diphtheritis 
of  the  nose  and  pharynx,  occurring  in  children  from 
four  to  fourteen  years  of  age.  From  the  anatomical 
description  of  the  two  dissections  of  Wreden's,  it  is, 
however,  not  certain  that  an  extension  of  the  diph- 
theritic process  from  the  pharynx  to  the  mucous 
membrane  of  the  middle  ear  had  taken  place,  a  fact 
which  has  already  been  emphasized  by  Wendt.^ 

Klipper^  found  with  diphtheritis  of  the  pharynx 
a  croupous  inflammation  in  the  Eustachian  tub;^  and 
tj-mpanum. 

Caseous  Inflammation  of  the  tj-mpanic  mucous  mem- 
brane scarcely  ever  exists,  except  in  chronic  tubercu- 
losis^ with  simultaneous  miliary  tuberculosis,  and  is 
never  found  without  defect  of  the  membrana  tym- 
pani.  It  may  also  possibly  occur  in  congenital  syphi- 
lis. The  purulent  exudation  which  is  mixed  with 
desquamated  epithelium  loses  its  fluid  constituents  by 
resorption  of  its  serum,  and  forms  grayish-yellow  or 
yellowish-white  masses,  which  are  generally  firmly 
imbedded  in  the  tissue  of  the  swollen  mucous  mem- 

1  A.  f.  0.,  I,  S.  203. 

2  Arch.  f.  Hellkunde,  xi.,  S.  260. 
3ili.  /  O.,  1868,  Xo.  10. 

4  /.  c,  S.  259. 
^  A.  f.  0.,  xi.,  S.  20. 

®  Joseph  Hamernjk;,  Ueher  Taubheit  und  Halbseitige  Gesichtdahmung  im 
Verlaufe  der  Tuberculose,  1844.     Zeitsch:  d.  Wiener  Aertze,  Sept. 


THE    TYMPANUM.  105 

brane,  and  infiltrate  this  tissue  with  fatty  pus-cells 
and  detritus.  Rapid  ulceration  follows  with  loss  of 
the  mucous  membrane,  and  with  apparent  polypoid 
degeneration  of  its  tissue,  and  sometimes  carious  de- 
struction of  the  neio;hborino:  bone  occurs. 

This  caseous  inflammation  should  not  be  confounded 
with  inspissation  or  caseous  metamorphosis  of  pus, 
which  is  extremely  frequent  in  the  tympanum  and 
antrum  mastoideum. 

Adhesive  Inflammation  and  Sclerosis.  The  t^^ipanic 
mucous  membrane,  like  the  serous  membranes,  shows 
a  marked  tendency  to  adhesive  inflammation,^  with  a 
new  growth  of  vascular  connective  tissue  in  the  form 
of  membranes,  bands,  strings,  and  threads.  Every 
form  of  catarrhal  inflammation,  serous,  mucous,  or 
purulent,  may  lead  to  these  growths,  but  they  appear 
to  be  especially  common  with  the  serous  exudation. 
Strictly  speaking,  this  is  not  a  special,  separate  spe- 
cies of  inflammation,  but  only  a  variety.  All  investi- 
gators agree  on  the  great  frequency  with  which  these 
bands  are  found  in  the  tympanum.  Even  to  the  older 
physicians  their  existence  w^as  not  unknown  (Mor- 
gagni).  In  1,013  diseased  ears,  Toynbee  found  them 
in  202,  or  twenty  per  cent.  Of  the  direct  adhesion 
of  the  niembrana  tympani  with  the  medial  wall  of  the 
tympanum  (promontorium),  with  the  long  process  of 
the  incus,  and  with  the  stapes  we  have  already  spoken 
in  the  chapter  on  the  drum-membrane.^    This  adhe- 

1  Morgagni,  De  Sedibus  et  Causis  Morborian,  i.,  Epist.  xiv.,  S.  15. 
Toynbee,  Diseases  of  the  Ear,  18G0,  pp.  272-275.  Von  Troeltsch,  Lehr- 
buch.  Politzer,  Beleuchtunf/shilder,  etc.,  S  109.  Gi'uber,  Lehrhucli,  S.  438 
and  557.  Wendt,  Arcliio  f.  He'dkunde  von  Wagner,  xv.,  S.  98.  Zaufal, 
A.  f.  O.,  v.,  S.  38. 

2  Pas-e  74. 


106  PATHOLOGY  OF   THE  EAR. 

sion  is  produced  by  the  two  epithelial  surfaces  of  the 
mucous  membrane  which  lie  in  contact  being  de- 
stroyed by  pressure,  and  then  the  tissue  of  the  mu- 
cous membrane  becomes  changed  into  a  vascular 
granulation  tissue,  which  is  sul)ject  to  the  usual  cica- 
tricial contraction.  The  union  of  the  mucous  sur- 
faces may  also  take  place  directly  by  proliferation 
from  the  contiguous  conical  and  dendriform  protu- 
berances of  the  membrane,  and  thus  the  apparent 
cysts,  spoken  of  in  the  chapter  on  the  drum-mem- 
brane, are  formed.^  These  cavities  are  nothing  more 
than  gaps  between  the  adherent  protuberances  of 
the  two  mucous  surfices  (Wendt).  Specially  narrow 
tympana  are  particularly  predisposed  to  such  adhe- 
sive processes,  as  are  also,  in  the  normal  cavity,  those 
spots  the  least  widely  separated  from  each  other  (Von 
Troeltsch).  Closure  of  the  Eustachian  tube,  by  caus- 
ing the  membrana  tympani  to  approach  the  laby- 
rinthine wall,  and  depression  of  that  membrane  from 
an  external  mass  of  cerumen  lying  against  it,  also 
favor  these  adhesive  processes  by  narrowing  the  tym- 
panic cavity. 

Still  more  common  than  this  direct  union,  with  the 
consequent  diminution  in  the  size  of  the  tympanum, 
are  the  so-called  pseudo-membranous  growths.  They 
occur  simultaneously  in  various  forms  in  the  same 
ear,  and  may  be  so  numerous  that  the  whole  cavity 
appears  to  be  filled  with  an  irregular  net-work.  They 
are  so  common  that  they  are  found  in  about  every 
fifth  ear  (Wendt).  When  recent  they  appear  of  a 
red  or  grayish-red  color,  soft  and  succulent  from 
serous  infiltration ;  when  old,  whitish-gray,  or  white 

1  Pao-e  81. 


THE    TYMPANUM.  107 

and  firm.  Confounding  them  with  simple  stringy 
mucus,  which  is  often  found  in  similar  shapes,  is  only 
possible  from  a  very  superficial  observation.  Open- 
ings can  be  seen  in  the  pseudo-membranes,  even  with 
the  naked  eye ;  in  the  thread-like  synechiie  they  are, 
however,  visible  only  under  the  microscope.  Their 
situation  is  extremely  variable ;  they  may  unite  the 
ossicula  with  each  other  or  with  the  walls  of  the 
t^'mpanum ;  the  drum-membrane  with  the  tympanic 
walls,  the  stapes,  or  the  long  process  of  the  incus ; 
the  tendon  of  the  tensor  tj'mpani  muscle  with  the 
roof  of  the  cavity  or  the  ossicula ;  very  frequently 
an  arm  of  the  stapes  with  the  walls  of  the  fenestra 
ovalis.  The  fenestra  rotunda  and  the  ostium  tym- 
panicum  tubje  may  also  be  completely  or  partially 
covered  by  them,  thus  causing  complete  or  partial 
closure  of  those  openings. 

When  these  adhesive  processes  are  extensive,  the 
tendon  of  the  tensor  tympani  is  almost  always  in- 
volved. By  large  membranes  the  tympanum  may 
be  divided  into  separate  cavities. 

An  influence  on  the  sound-conduction  of  the  tym- 
panic apparatus  can  only  be  ascribed  to  those  bands 
which  are  tense  and  rigid,  and  which  also  bind  down 
or  touch  the  separate  parts  of  this  conducting  ap- 
paratus, or  else  when  they  are  situated  on  parts  of 
special  acoustic  importance.  On  the  ossicula,  for 
instance,  tense  synechia)  of  the  stapes  would  be  much 
more  injurious  than  the  same  would  be  on  the  incus 
or  malleus,  on  account  of  the  minuteness  of  the  nor- 
mal vibrations  of  the  stapes.  Small  synechise  on  the 
stapes  are  sufficient  to  reduce  the  hearing  as  much  as 
extensive  membranes  between  the  drum-membrane 
and  labyrinthine  wall  would  do. 


108  PATHOLOGY  OF   THE  EAR. 

Many  of  these  membranous  bridges  are  not  pro- 
duced by  pathological  processes,  but  are  the  remains 
of  the  mucous  tissue  which  fills  the  tympanum  of  the 
foetus  and  new-born  child  ;  they  are  the  result  of  in- 
complete retrogression  of  this  tissue,  a  sort  of  arrest 
of  development.-^  The  occasional  duplicatures  of  the 
mucous  membrane  between  the  long  process  of  the 
incus  and  the  manubrium  or  the  inner  tympanic 
wall,  and  between  the  tendon  of  the  tensor  tympani 
muscle  and  the  tympanic  roof  are  referable  to  this 
cause. 

The  pathological  connecting-bands  are  produced 
(1)  by  the  contact  and  union  of  portions  of  the  mu- 
cous membrane,  when  in  a  condition  of  swelling  and 
proliferation;  (2)  by  the  formation  of  granulations 
during  suppurative  processes,  as  in  ulceration  of  the 
mucous  membrane  or  of  the  bone.  If  adhesion  has 
taken  place  on  one  or  many  minute  spots,  the  retro- 
gression of  the  swelling  of  the  mucous  membrane 
leaves  string  or  thread-like  synechige,  due  to  the  draw- 
ing out  and  shriveling  of  the  conical  protuberances 
on  the  mucous  surfaces,  which  have  become  united 
together.  If,  instead  of  adhesion  in  minute  spots,  an 
extensive  surface  has  become  adherent,  membranes, 
instead  of  thread-like  synechiae,  are  formed.  In  either 
case,  a  simple  duplicature  of  the  mucous  membrane 
is  formed  covered  with  a  cubic  or  pavement  epithe- 
lium, very  deficient  in  cellular  elements  and  blood- 
vessels, and  consisting  entirely  of  connective  tissue 
with  elastic  fibres.  In  this  connective  tissue,  a  thin 
envelope  of  loose,  wide-meshed,  pliable  tissue  can  be 

1  Hinton,  Guy's  Hospital  Reports,  1863,  vol.  ix.,  pp.  264-268.    Politzer, 
Beleuchtungsbilder,  1865,  S.  109. 


THE    TYMPANUM.  109 

distinguished,  in  which  a  fine,  slender  net-work  of 
capilkiries  is  distributed ;  this  is  the  subepitliehal 
layer  of  the  mucous  membrane.  Surrounded  by  this 
envelope  are  bundles  of  parallel,  firm,  tense  fibres,  in 
the  form  of  a  frame-work  which  incloses  the  coarser 
capillaries,  and  the  few  minute  arteries  and  veins 
wdiich  nourish  the  tissue ;  this  is  the  periosteal  layer 
of  the  mucous  membrane.  By  atrophy,  and  by 
mechanical  irritation,  produced  by  variations  in  the 
air-pressure,  as  by  sneezing,  blowing  the  nose,  etc., 
membranes  may  become  simple  thread-like  sjnechiae, 
and  the  openings,  which  are  frequently  found  in  the 
membranes,  are  referable  also  to  these  same  causes. 

The  synechias  produced  by  the  union  of  true  gran- 
ulations are,  when  recent,  distinguished  by  the  char- 
acter of  their  tissue  and  by  the  absence  of  an  epithe- 
lial coverino;. 

In  fully  developed  membranes  and  synechia?  of  an 
old  date,  it  is  impossible  to  distinguish,  either  from 
the  histological  examination,  or  from  their  situation, 
wdiether  they  are  the  remains  of  the  foetal  mucous 
cushion,  or  of  a  pathological  swelling.  The  latter 
may  completely  disappear  without  leaving  any  ana- 
tomical changes.  If  marked  atrophy  of  the  adhesions 
has  taken  place,  it  may  be  said  with  certainty  that 
they  date  from  a  swelling  which  has  long  since  passed 
away,  and  often  that  they  date  from  the  foetal  tissue 
(Wendt). 

These  connecting-bands,  even  if  quite  old,  share  in 
new  diseases  of  the  ear  (hypersemia,  interstitial  ex- 
travasations), and  suffer  further  changes  of  a  regres- 
sive or  progressive  kind.  In  addition  to  the  already 
described  atrophy,  they  are  subject  to  the  deposition 


110  PATHOLOGY  OF   THE   EAR. 

of  fat  ill  the  cells  of  the  connective-tissue  stroma,  to 
sclerosis,  to  cicatricial  contraction,  to  calcification, 
and  to  ossification.  From  all  of  these  processes  their 
physical  characteristics  may  be  altered  so  that  they 
interfere  with  the  conduction  of  sound. 

(1.)  AirojjJiy  may  cause  partial  or  comjolete  disap- 
pearance of  the  new-growths,  perhaps  favored  by  the 
positive  air-pressure  in  the  tympanum,  which  occurs 
spontaneously  in  sneezing,  blowing  the  nose,  etc.,  or 
artificially  from  the  air-douche. 

(2.)  Sclerosis.  The  fibres  of  connective  tissue 
become  tense,  and  assume  a  parallel  arrangement, 
become  apparently  thicker,  and  look  rigid,  fragile, 
and  opaque.  Here  and  there  long  spaces  are  formed 
between  them,  filled  with  a  finely  granular  contents, 
which  is  but  little  altered  by  the  addition  of  acids. 
These  spaces  occasionally  show  encapsuled  cells.  The 
fibres  resemble  somewhat  the  processes  of  the  lamina 
propria. 

(3.)  Cicatricial  contraction  shows  thickly  crowded, 
tense  fibrillae,  generally  parallel,  but  occasionally  in- 
terwoven with  each  other.  The  tissue  is  very  firm, 
and  with  difficulty  picked  to  pieces.  The  fragility 
and  marked  opacity  seen  in  the  sclerotic  fibres  is 
wanting.  The  fixed  cells  are  more  numerous  than  in 
sclerosis.  Cicatricial  thickening  is  found  not  only  in 
the  synechiae  produced  from  granulations,  but  also 
in  the  common  duplicatures  of  the  mucous  membrane. 

(4.)  Calcifications  occur  only  on  the  inner  zone  of 
the  connective  tissue,  which  corresponds  with  the  per- 
iosteal layer  of  the  mucous  membrane.  The  lime  is 
found  deposited  in  molecules  in  slit-like  spaces  be- 
tween the  separate  fibrillar,  or  between  bundles  of 


THE    TYMPANUM.  Ill 

fibrillre.  These  spaces  sometimes  appear  to  have  a 
fusiform  arrangement,  and  may  be  wholly  filled  by 
the  lime. 

(5.)  Ossification  may  occur  within  calcified  mem- 
branes in  the  form  of  separate  islets  or  of  large 
lamellae.  Bone  corpuscles,  with  their  processes,  are 
seen  in  a  homogeneous,  hard,  glistening  stroma,  which, 
on  the  addition  of  muriatic  acid,  shows  no  striation. 

Sclerosis  of  the  tympanic  mucous  membrane  (indu- 
ration, dry  catarrh,  rigidity  of  the  tympanic  mucous 
membrane  (Toynbee),  chronic  periostitis  of  the  iym- 
panum)  is  a  clinical  designation,  used  by  aural  sur- 
geons, which  only  partially  describes  the  histological 
condition.  \o\\  Troeltsch,  who  first  introduced  this 
name  into  the  otological  terminology,  wished  to  des- 
ignate thereby  only  the  gross  appearances  and  the  ma- 
croscopic condition  of  the  mucous  mendjrane,  which 
appears  thicker,  stiffer,  and  less  elastic  than  in  the 
normal  condition.  The  result  of  this  change  is  rig- 
idity of  the  articulations  of  the  ossicles,  and  conse- 
quent increased  resistance  to  the  conduction  of  sound 
through  the  tympanic  apparatus.  The  most  frequent 
ultimate  result  is  anchylosis  of  the  stapes. 

The  histolou-ical  chang-es  which  are  the  foundation 
of  the  so-called  sclerosis  are  of  various  kinds.  Only 
in  a  small  proportion  of  the  cases  is  there  really  a 
connective-tissue  sclerosis  of  the  deep  periosteal  layer 
of  the  mucous  membrane,  with  cellular  infiltration  of 
the  subepithelial  layer ;  but  when  this  does  exist,  the 
connective  tissue  of  the  deeper  layer,  normally  ar- 
ranged in  fibrilla?,  shows  tendinous  bundles,  like  the 
tendinous  processes  of  the  membrana  propria.  These 
bundles  appear  homogeneous,   brittle,   opaque,  with 


112  PATHOLOGY  OF   THE  EAR. 

parallel  or  slightly  waving  fibres,  and  spaces  between 
these  fibres  filled  Avith  a  few  encapsuled  cells,  or  with 
a  finely  granular  and  crumbling  mass  (Wendt).  In 
this  condition  the  vessels  are  only  few  in  number, 
and  the  ej^lthelium  and  subeintheUal  connective-tissue 
may  remain  perfectly  normal,  or  the  latter  may  like- 
wise undergo  thickening. 

More  commonly,  however,  this  deep  periosteal  layer 
is  richly  impregnated  Avith  finely  granular  lime-salts, 
with  here  and  there  spindle-shaped  spaces  free  from 
the  deposit,  or  with  spots  of  osseous  new  growth,  ossi- 
fying periostitis.  In  still  other  cases,  according  to 
Von  Troeltsch,  there  is  a  cicatricial  contraction,  with 
thickening  of  a  previously  swollen,  infiltrated,  and 
hypersemic  tissue. 

As  the  results  of  sclerosis,  should  be  mentioned 
the  changes  which  take  place  on  the  membrane  of 
the  fenestra  rotunda;  namely,  thickenings,  deposits 
of  lime  and  of  large  round  cells  in  its  connective- 
tissue  stroma  (Wendt). 

All  these  changes  are  the  secondary  results  of 
chronic  inflammation,  and  ma}^  occur  after  a  serous, 
mucous,  or  purulent  exudation,  or  may  exist  with 
any  of  these  exudations.  Only  when  this  fact  is 
borne  in  mind  is  the  term  sclerosis,  which  originated 
from  clinical  necessity,  justifiable.  Whether,  in  fact, 
cases  of  circumscribed  sclerosis  of  the  tympanic  mu- 
cous membrane  occur,  in  which  the  disease  is  wholly 
confined  to  certain  limited  portions  of  membrane,  as, 
for  instance,  the  fenestra  ovalis,  and  thus  producing 
anchylosis  of  the  stapes,  remains  to  be  investigated 
histologically.  From  macroscopic  examination  such 
a  condition  can  scarcely  be  doubted.     The  only  ques- 


THE   TYMPANUM,  113 

tion  is,  whether  in  such  cases  an  extensive  disease  of 
the  periosteal  layer  of  the  mucous  membrane,  pro- 
ducing only  at  certain  points  gross,  macroscojoic 
chani»:es,  is  not  at  the  bottom  of  the  trouble. 

Caries  of  the  Tympanum.  Purulent  catarrh  of  the 
tympanum  may  lead  to  ulceration  of  the  mucous  peri- 
osteal lining  of  the  cavity  by  which  the  bone  is 
exposed,  and  very  soon  attacked  by  the  ulcerative 
process.  In  this  way  circumscribed  caries  in  the  tym- 
panum occurs  on  the  roof,  labyrinth  wall,  and  other 
places,  but  especially  often  on  the  thin  osseous  lam- 
ella, which  separates  the  cavity  Avhere  the  head  of  the 
malleus  lies  from  the  external  meatus.  I  have,  how- 
ever, seen  circumscribed  caries  on  the  labyrinth  wall, 
with  simultaneous  thickening  of  the  lining  membrane 
of  the  tympanum  without  ulceration.  Carious  de- 
struction of  the  tympanic  walls  and  of  the  ossicula  is 
exceptional,  with  an  imperforate  drum-membrane.  If 
the  carious  spot  is  on  the  wall  of  the  labyrinth  it  can 
frequently  be  recognized  through  the  perforation  of 
the  membrana  tympani  by  the  yellowish  discolora- 
tion, roughness,  and  irregular  margin  of  the  ulcerated 
mucous  membrane. 

By  perforation  of  the  Fallopian  canal,  facial  paraly- 
sis may  be  produced  from  the  pressure  of  the  exu- 
dation on  the  trunk  of  the  nerve,  or  from  neuritis.^ 
Yet  in  cases  where  dissection  shows  a  carious  destruc- 
tion of  the  canal,  the  facial  paralysis  during  life  is 
sometimes  absent  (Gruber). 

Both  labyrinthine  fenestrae  may,  by  caries,  be  fused 
into  a  single  large  opening  in  the  labyrinth  wall.     By 

1  Tillmanns,  Ueher  FaciaUslalimung  hei  Ohrkranklieiten.   Diss.  Inaug., 
Halle,  1869. 


114  PATHOLOGY  OF   THE  EAR. 

Still  greater  destruction  the  tympanic  and  labyrinth- 
ine cavities  may  form  a  common  cavity  communicat- 
ing with  the  posterior  fossa  of  the  skull. 

After  the  healing  of  a  caries  of  the  tympanum,  the 
perforation  of  the  drum-membrane  may  close  by  cica- 
tricial formation,  but  usually  an  injury  of  the  hearing 
remains,  the  cause  of  which  may  be  adhesive  inflam- 
mation within  the  cavity ;  numerous  cicatricial  bands 
may  unite  and  bind  down  the  ossicula  with  each 
other,  and  with  the  drum-membrane  and  the  tym- 
panic walls. 

Pathological  Changes  of  the  Ossicula  and  their  Attach- 
ments. Carious  destruction  of  the  ossicles^  is  very  com- 
mon, and  may  occur  at  all  ages.  There  may  be  loss 
of  certain  parts  of  the  bones,  or  the  bones  themselves 
may  be  completely  freed  from  their  attachments, 
change  their  natural  positions,  form  new  and  abnormal 
attachments,  or  be  wholly  expelled.  The  most  com- 
mon cause  of  these  changes  are  the  acute  suppurative 
processes  of  the  mucous  membrane  covering  the  ossi- 
cles, which  occur  during  scarlet  and  typhus  fevers,  or 
else  the  chronic  suppurations  in  scrofula  and  tubercu- 
losis. The  existence  oi  primary  ostitis  of  the  ossicles 
is  also  not  to  be  denied.^ 

On  the  hammer,  with  extensive  loss  of  the  drum- 
membrane,^  there  is  frequently  a  destruction  of  the 
lower  end  of  the  manubrium.^ 

1  Schwai'tze,  SitzunfjsprotocoU  der  Section  fiir  Ohrenlteilkunde  auf  der 
Naturforscher-Versammlung  in  Wiesbaden,  1873,  A.f.  0.,  viii.,  S.  226. 

2  Vide  Von  Troeltsch,  A-  /■  0.,  vi.  S.  55. 
8  Vide  Fig.  40. 

*  Carious  loss  in  the  middle  of  the  manubrium,  by  which  that  bone  is 
separated  into  two  parts,  occurs  very  rarely.  Wendt  found,  in  one  case, 
the  separated  ends  .of  the  bone  united  by  a  soft,  red  band  of  tissue. 


THE    TYMPANUM.  115 

Circumscribed  destructive  processes  on  the  head  of 
the  hammer,  without  an  affection  of  the  manubrium, 
are  by  no  means  rare,  even  without  an  extensive 
defect  in  the  membrana  tympani  (Fig.  59).  Circum- 
scribed granulations  on  the  upper  portion  of  the 
drum-membrane,  around  the  short  process,  would 
arouse  suspicion  that  there  existed  such  an  isolated 
caries  on  the  head  of  the  hammer.  The  manubrium 
may  remain  in  the  drum-membrane,  even  if  the  head 
of  the  hammer  is  separated  by  caries  and  expelled 
(Fig.  58).  ^ 

On  the  incus  the  processes  may  be  lost,  the  long 
one  first  of  all,  and  the  corpus  incudis  then  falls 
away  from  its  connection  with  the  head 
of  the  hammer;  more  rarely  the  pro-  ^p 
cesses  remain  and  only  the  body  of  the 
bone  shows  carious  roughness.  Some- 
times the  incus,  even  with  an  imperfo- 

'  A  Figs.  58,   59. 

rate   drum-membrane,  is  loosened  from     pic.  53.  carious 
its  connections  and  destroyed  by  caries.  Head  of  the  Manu- 

0. 1  ,  .  1       ,  ,  •  •       brium    thrown    off 

n   tne    stapes    carious    destruction   is  during  iife. 

chiefly   confined   to    the   head   and   the     ^^g-^^-  cadous 

111  Excavation   on   the 

crura.  Not  unfrequently  both  crura  Head  of  the  Ham- 
are  lost,  but  the  base  usually  remains  ™"' 
in  its  attachments  covered  by  a  hypertrophied  mu- 
cous membrane,  or  by  a  growth  of  connective  tissue. 
The  marked  resistance  of  the  base  of  the  stapes  to 
the  destructive  inflammatory  processes  of  the  tym- 
panum is  apparently  explained  by  the  fact  that  it 
receives  part  of  its  nutrition  from  the  vessels  of  the 
labyrinth.  I  found  partial  destruction  of  the  base 
once  in  a  child,  which  died  from  miliary  tuberculosis. 
While  malleus  and  incus  are  frequently  throw^n  off 


*/ 


116  PATHOLOGY  OF   THE  EAR. 

during  life  in  a  state  of  necrosis  from  suppurative 
processes,  as  in  scarlet  fever,  this  is  very  rarely  the 
case  with  the  stapes.  Up  to  the  year  1873,  I  myself 
had  never  observed  it;  since  then  such  a  case  has 
been  observed  by  Dr.  Boeck,  of  Magdeburg,  and  a 
short  time  afterwards  two  cases  occurred  in  my  own 
practice. 

The  case  of  Boeck,  observed  in  1867,  is  for  other 
reasons  remarkable,  and  I  therefore  give  it :  — 

Wittling,  a  manufacturer,  forty-five  years  old,  previously  healthy, 
and  of  strong  constitution,  as  the  result  of  exjiosure  to  a  draft  of 
air  suffered,  in  the  summer  of  1866,  from  the  usual  symptoms  of  an 
acute  otitis  media  purulenta  sinistra.  Disease  of  the  bone  was  not 
suspected.  On  the  30th  of  December,  he  suddenly  had  two  epileptic 
attacks,  at  an  interval  of  half  an  hour.  Dr.  Boeck  saw  the  second 
attack  and  describes  it  in  the  following  language :  "  The  patient 
was  seized  in  the  midst  of  a  sentence,  repeated  the  last  word  si^oken 
at  first  slowly,  then  more  and  more  rapidly  for  thirty  or  forty  times  ; 
the  gaze  was  fixed  and  the  right  hand  raised ;  these  symptoms  were 
followed  by  loss  of  consciousness  and  a  regular  epileptic  attack 
lasting  from  ten  to  fifteen  minutes.  Such  attacks  were  repeated 
twice  at  short  intervals,  and  never  recurred  afterwards.  From  that 
time  the  patient  suffered  continuously  from  dizziness  and  uncer- 
tainty of  gait,  so  that  he  was  unable  to  walk  without  being  led. 
Polypoid  granulations  were  developed  in  the  meatus,  which  rapidly 
grew  again  after  removal,  and  there  was  a  very  copious  otorrhoea. 
On  the  8th  of  March,  1867,  while  the  ear  was  being  syringed,  the 
stapes  in  a  perfect  state  was  removed.  Its  base  appeared  somewhat 
roughened  on  its  vestibular  side  when  examined  by  a  magnifying 
glass.  The  patient  died  from  rapid  consumption  of  the  lungs  on 
May  4,  1867.     There  was  no  autopsy. 

On  the  malleus  and  incus,  Von  Troeltsch^  has  found 
a  flattening  due  to  atrophy  from  pressure,  when  the 
drum-membrane  was  strongly  drawn  inwards  and 
pressed  against  the  labyrinth  wall. 

^  A.  f.  O.,  viii.,  S.  230. 


THE    TYMPANUM.  117 

Softening  of  the  ossicula  in  osteomalacica  has  been 
described  by  Morand.^ 

In  general  osteosclerosis  of  the  skull,  as  in  syphilis, 
the  ossicula  are  found  very  heavy  and  full. 

In  injuries  from  penetration  of  the  ear,  fractures 
of  the  ossicles  occur,  particularly  in  the  manubrium 
(Fig.  54). 

Loosening  and  separation  of  the  articulations.  The 
articulating  capsule  between  the  incus  and  stapes 
may  become  so  relaxed  that  a  sort  of  subluxation 
may  occur.  When  tiie  membrana  tympani  is  strongly 
drawn  inwards  it  is  quite  common  to  see  the  little 
depression  on  the  head  of  the  stapes  lying  against 
that  membrane,  giving  an  appearance  as  though  the 
stapes  was  wholly  separated  from  its  articulation  with 
the  incus.  The  fact  however  is,  that  the  incus  is  only 
pushed  aside  within  the  distended  and  relaxed  cap- 
sule. This  relaxation  of  the  capsular  band  is  some- 
times found  particularly  marked  with  synostosis  of 
the  stapes  in  the  fenestra  ovalis  (Magnus). 

Complete  separation  of  the  articulations,  diastasis 
of  the  ossicula,  occurs  most  easily  between  the  incus 
and  stapes,  as  the  result  of  purulent  inflammation, 
which  destroys  and  throws  off  the  os  Sylvii  lying  be- 
tween them.  The  artificial  diastases,  produced  by  a 
careless  dissection,  are  readily  distinguished  from  the 
pathological  by  the  healthy  condition  of  the  articu- 
lating surfaces  of  the  ossicles,  and  by  the  fact  that 
the  OS  Sylvii  usually  remains  attached  to  the  long 
process  of  the  incus.  Relaxation  of  the  firm  articu- 
lating capsule  between  the  malleus  and  incus  seldom 
occurs  with  inflammations.    I  have  described  one  such 

1  Quoted  by  Bonnafont,  p.  539. 


118  PATHOLOGY  OF   THE  EAR. 

case,  associated  with  superficial  caries  of  the  articu- 
lating surface  of  the  body  of  the  incus,  and  atrophy 
of  the  musculus  tensor  tympani  and  musculus  sta- 
pedius.^ I  saw  a  similar  case  with  Professor  Zaufal, 
which  was  associated  with  innnobility  of  the  incus. 

From  injuries  of  the  skull  with  fissure  of  the  pe- 
trous bone  diastasis  of  the  ossicula  may  take  place. 
In  one  case  I  saw  this  condition  associated  with  a 
paralysis  of  all  the  muscles  of  the  eye  on  the  same 
side. 

Blumenbach  ^  asserts  that  hydrocephalus  may  be  the  cause  of  dias- 
tasis, the  pars  petrosa  and  squamosa  being  so  separated  from  each 
other  that  the  incus  is  completely  separated  from  the  stapes,  and  the 
malleus  and  incus  remain  connected  with  the  squamous  portion  of 
the  bone  and  are  drawn  downwards.  In  one  case  he  asserts  that  he 
saw  the  stapes  lifted  out  of  the  foramen  ovale.  I  give  this  on  the 
authority  of  Blumenbach,  having  had  no  experience  of  my  own  with 
this  condition. 

Rigidity  and  immohillty ,  anchylosis,  is  very  com- 
mon in  the  annular  ligament  of  the  stapes  and  in  the 
malleo-incus  articulation . 

The  normal  movement  of  the  base  of  the  stapes  is 
very  small.  Helmholtz  found  that  the  excursions  of 
the  stapes  were  from  iV  to  tV  mm. ;  from  this  it  is 
evident  that  the  appreciation  of  the  pathological  im- 
pairment of  mobility  is  extremely  difficult,  and  the 
diagnosis  of  rigidity  is  often  quite  arbitrary.  On  this 
account  Politzer  has  proposed  to  measure  accurately 
the  degree  of  mobility  by  inserting  a  fine  manometer 
tube  filled  with  a  solution  of  carmine,  air-tight,  into  the 
superior  semicircular  canal,  and  then  measuring  the 

1  ArcMv  fur  OhrenlieiUcunde,  ii.,  S.  290. 

^  GeschicJde  und  Besclireibung  der  Knochen,  2  Auflage,  S.  151,  note  1. 


THE    TYMPANUM.  119 

variations  of  the  fluid  in  the  tube  during  changes  of 
air  pressure  hi  the  meatus.^ 

The  recognition  of  complete  anchylosis  of  the  stapes 
is  very  easy  and  can,  if  doubtful,  be  determined  with 
certainty  from  the  fact  that  no  change  occurs  in  the 
lio-ht-reflex  on  the  membrane  of  the  fenestra  rotunda 

o 

when  the  stapes  is  pressed  upon,  or  if  this  light-reflex 
is  obscyred  by  swelling  of  the  mucous  membrane,  a 
drop  of  fluid,  placed  in  an  opening  made  into  the  ex- 
ternal semicircular  canal,  w^ill  answer  the  same  pur- 
pose. 

The  capability  of  vibration  in  the  ossicula  is  dimin- 
ished by  thickening  or  rigidity  of  the  mucous  mem- 
brane which  covers  these  bones  (sclerosis,  calcification 
or  ossification  of  the  periosteal  connective  tissue  with 
cellular  and  serous  infiltration  of  the  subepithelial 
layer),  by  synechia3  and  by  the  imbedding  of  the 
bones  in  hypertrophied  connective  tissue  (membra- 
nous anchylosis).  A  very  common  cause  of  rigidity 
of  the  stapes  is  stifliiess  of  its  annular  ligament,  pro- 
duced by  a  deposition  of  lime  in  the  membrane,  which 
is  often  associated  with  similar  depositions  in  the  mu- 
cous membrane  of  the  stapes  itself  and  of  the  promon- 
tory. If  the  whole  annular  ligament,  or  even  only 
the  periosteal  layer  of  the  mucosa  which  covers  it,  is 
changed  into  a  mass  of  lime,  absolute  immobility,  an- 
chylosis of  the  stapes,  results.  The  same  result  is 
produced  by  a  new  growth  of  bone,  hyperostosis,  on 
the  base  of  the  stapes,  on  the  promontory,  and  on  the 
foramen  ovale  ;  by  osseous  bridges  between  the  crura 
and  the  walls  of  the  niches  and  by  the  direct  pinching 
of  the  crura  in  a  foramen  ovale  much  narrowed  by 

1   Wiener  Med.  Wochensclir.,  1862,  S.  214. 


120  PATHOLOGY  OF  THE  EAR. 

hyperostosis.  A  predisposition  to  such  synostosis  of 
the  stapes  with  the  foramen  ovale  is  produced  by  ad- 
vanced age,  possibly  because  at  this  time  the  cartilage 
covering  the  periphery  of  the  base  of  the  stapes  and 
the  edges  of  the  foramen  ovale  suffers  a  physiological 
degeneration. 

The  existence  of  anchylosis  of  the  stapes  is  how- 
ever by  no  means  confined  to  old  age  ;  but^ay  be 
found  at  all  ages,  and  is  even  sometimes  congenital, 
the  result  of  intrauterine  inflammation.^  T  have  met 
w^ith  it  very  frequently  in  dementia  paralytica.  Ac- 
cording to  Toynbee,  arthritis  and  rheumatism  are  the 
most  important  factors  in  its  aatiology.  It  remains  to 
be  investigated  whether  primary  diseases,  calcification 
and  ossification,  of  the  cartilaginous  coverings  of  the 
ossicula  do  not,  more  commonly  than  is  supposed, 
predispose  to  rigidity  and  synostosis. 

Anchylosis  of  the  stapes  is  found  only  exceptionally 
without  gross  pathological  changes  of  the  whole  lin- 
ing membrane  of  the  tympanum.  As  a  rule  liyperiB- 
mia,  thickening,  and  synechijB  are  found  together  with 
whitish  opacities  on  the  membrana  tympani. 

After  complete  immobility  of  the  base  of  the  stapes 
has  existed  for  a  long  time  the  crura  become  atro- 
phied from  inactivity,  so  that  they  break  at  a  slight 
touch.  This  atrophy  of  the  crura  is  then  in  marked 
contrast  with  the  often  clearly  defined  hyperostosis  of 
the  base  of  the  bone,  which  may  project  into  the  ves- 
tibule, sometimes  producing  within  that  cavity  a  bony 
tumor  with  a  convex  surface. 

Another  secondary  result,  dependent  on  the  defi- 

1  According  to  Gegenbauer  anchylosis  of  the  stapes  is  perhaps  in  some 
animals  a  normal  condition. 


THE    TYMPANUM.  121 

cient  mobility  of  the  base  of  the  stapes,  is  a  new 
growth  of  cartilage  in  the  annular  ligament ;  this  pro- 
ceeds from  the  cartilage  of  the  foramen  ovale  and  is 
analogous  to  the  new  growths  of  cartilage  in  anchy- 
losed  joints.^  A  synostosis  between  malleus  and  incus, 
following  a  previous  diastasis  of  the  bones,  was  de- 
scribed by  me.^ 

Malleus  and  incus  may  become  ossified  with  the 
upper  wall  of  the  tympanmn. 

Exostoses  ^  on  the  ossicula,  the  result  of  ossifying 
periostitis,  without  suppuration  of  the  tympanum  and 
without  perforation  of  the  drum-membrane,  are  com- 
mon on  the  incus,  where  the  point  of  preference  is  on 
the  lab^'rinth-side  of  the  end  of  the  short  process ; 
they  are  less  common  on  the  malleus  and  least  com- 
mon on  the  stapes.  The  space  between  the  long  and 
short  processes  of  the  incus  was  found  by  Wendt 
filled  with  a  new  growth  of  bone,  in  a  woman  sixty- 
five  years  of  age,  who  had  suffered  from  arthritis. 
On  the  end  of  the  manubrium  of  a  child,  after  sup- 
puration of  the  tympanum  which  had  left  a  persistent 
kidney-shaped  opening  in  the  membrana  tympani,  I 
once  saw  an  exostosis  the  size  of  a  small  pea,  possibly 
an  ossified  enchondroma.  Toynbee  also  describes  an 
exostosis  on  the  manubrium.^  Enchondromata  ap- 
parently are  developed  quite  often  on  the  sharply 
projecting  processus  brevis,  such  as  is  seen  with  a 
retracted  drum-membrane. 

1  Compare    Wendt,  Archiv  der  Heilkunde   von  E.  Wagner,  xiv.,    S. 
286. 

■^A.f.  0.,  ix. 

3  Ilesselbacli,    Beschreibung    der    Patholog.,  Prdparate    zu    Wiirzburg, 
Giessen,  1824,  S.  126.    Toynbee,  Medical  Times  and  Gazette,  1859,  De- 
cember, p.  589. 
.•*  Catalogue,  No.  628. 


122  PATHOLOGY  OF   THE  EAR. 

Pathological  Changes  of  the  Tympanic  Muscles.  Idio- 
pathic primary  diseases  of  these  muscles  are  unknown  ; 
secondary  changes,  on  the  contrar}^,  have  been  fre- 
quently observed  with  chronic  inflammations  of  the 
tympanum.  From  long  impairment  of  their  functions 
as,  for  instance,  from  synechiiB  between  the  drum- 
membrane  and  the  promontory,  they  may  undei'go 
fatty  or  fibrous  degeneration,  or  may  become  atro- 
phied. True,  hyperplasia  of  the  muscles  has  been  less 
commonly  observed ;  it  has,  however,  been  found  in 
chronic  suppuration  of  the  tympanum  with  perfora- 
tion of  the  drum-memlDrane,  polypus  and  caries  of  the 
ossicula  (Wendt).  Extravasations  of  blood  within  the 
muscles  and  h^ematomata  on  the  tendon  of  the  tensor 
tympani  muscle  may  occur  during  congestive  catarrh. 

Shortening  of  the  tendon  of  the  tonsor  tympani 
may  result,  (1.)  From  connective-tissue  adhesions  be- 
tween the  tendon  and  its  sheath,  the  mucous  mem- 
brane covering  it.  This  is  so  common  that  it  has 
been  described  as  normal  by  some  anatomists,  as 
Henle,  but  without  doubt  the  normal  condition  is 
such  that  the  tendon  shall  move  freeh^  within  its 
sheath.  (2.)  From  retraction  of  the  thickened  mu- 
cous membrane  covering  the  tendon,  during  chronic 
thickening  of  the  general  tympanic  mucous  mem- 
brane, first  described  b}^  Politzer  ^  as  a  common  result 
from  long  closure  of  the  Eustachian  tube.  (3.)  From 
membranous  or  thread-like  synechia©  connecting  the 
sheath  of  the  tendon  with  the  roof  of  the  tympanum 
or  with  other  parts  of  that  cavity,  especially  the  long 
process  of  the  incus  and  the  stapes.  These  membra- 
nous new-growths  may  contain  osteoid  deposits. 

1  Beleuchtungshilder  des  Trommelfelh ,  S.  132. 


THE    TYMPANUM.  123 

Destruction  of  the  tendon  of  the  tensor  tympani  is 
very  common  during  suppurative  processes. 

Hinton  found  fibromata  oil  the  tendon  of  the  tensor 
tympani. 

Often  when  there  is  an  extreme  drawing;  inwards 
of  the  drum-membrane  and  partial  obliteration  of  the 
tympanum  the  tendon  is  completely  imbedded  in  the 
swollen  and  thickened  mucous  membrane  w^hich  lines 
the  tegmen  tympani. 

At  the  insertion  of  the  stapedius  muscle  Hyrtl  oc- 
casionally saw  a  small  bony  process  which  sometimes 
even  projected  into  the  body  of  that  muscle. 

Injuries.  -  Fractures  of  the  base  of  the  skull  often 
extend  through  the  tympanic  walls,  and  may  thus 
afford  communication  between  the  tympanum  and 
the  labyrinth  or  cranial  cavity. 

From  the  entrance  of  sharp  substances  through  the 
membrana  tympani  separation  and  dislocation  of  the 
ossicula  may  take  place. 

Foreign  bodies  sometimes,  when  the  drum-membrane 
is  uninjured,  reach  the  tympanum  through  the  Eusta- 
chian tube.  The  most  common  of  these  are  minute 
particles  of  coal-soot,  which  under  a  superficial  ex- 
amination could  be  mistaken  for  a  grayish-black  pig- 
mentation of  the  mucous  membrane  :  the  constituent 
parts  of  plants  and  hairs  have  also  been  found. 

During  expulsion  of  blood,  either  in  hremoptysis 
or  h^ematemesis,  blood  may  pass  into  the  tj^mpanum. 
Bits  of  food  and  bile  may  also  reach  the  cavity  dur- 
ino;  vomitino"- 

Foreign  bodies  entering  the  tympanum  from  the 
external  meatus,  after  injury  of  the  drum-membrane, 
may  give  rise  to  multifold   nervous   symptoms,  and 


124  PATHOLOGY  OF   THE   EAR. 

have  frequently  procliicecl  fatal  disease  of  the  brain, 
as  purulent  basilar  meningitis  and  abscess  of  the 
brain. 

New  Growths. 

AURAL    POLYPI. 

Th.  Wallstein,  De  quibusdam  Otitidis  Ext.  Formis.  Grypbiae,  1846. 
(Asserting  tlie  fact,  first  proven  by  Professor  Baum,  that  ciliated  epithe- 
lium is  found  on  aural  polypi).  Meissner,  Zeitschrift  f.  Rat.  Medicin 
1853.  S.  350.  (With  a  complete  index  of  the  literature.)  Wedl,  Grund- 
ziige  der  Patholog.  Histologic.  Wien,  1854.  S.  467.  Billroth,  Ueber  den 
Bau  der  Schleimpolypen.  Berlin,  1855.  S.  27.  Fors^er,  Atlas  der  Patho- 
logischen  Histologic.  S.  73.  1859.  Von  Troeltsch,  Yirchovf's  Arch.  XVH. 
S.  40,  41.  1859.  A.  f.  O.  IV.  S.  99  and  104  and  Lehrbucb.  Kessel, 
A.  f.  O.  IV.  S.  167.  1868.  Steudener,  K.i.O.  IV.  S.  199.  1868. 
Lucae,  Virchow's  Arch.     XXIX.     S.  39. 

Contrary  to  earlier  opinions,  by  far  the  greater 
number  of  aural  polypi  arise  without  doubt  from  the 
mucous  membrane  of  the  tympanum.  Even  in  cases 
where  they  appear  to  have  their  origin  in  the  skin  of 
the  meatus  anatomical  investigation  shows  that  in 
reality  they  arise  from  the  cavities  lying  above  the 
meatus,  which  are  a  part  of  the 
middle  ear,  and  lined  with  mucous 
membrane  (Yon  Troeltsch).  Pol- 
ypi vary  from  a  microscopic  size 
to  large  tumors,  three  or  four 
centimeters  long,  which  produce 
ulceration  of  the  drum-mem- 
'''^'  ^°'  '^'   '■      brane,  fill  and  project  out  of  the 

Fig.  60.  Smooth  Aural  Pol  v-  rr^,  •      i       i  i 

pus,  the  base  covered  with  lucatus.  ihcy  may  imbed  and 
smooth  papiii^.  surround   the    hammer,^    and    in 

Fig.    61.    Papillary    Aural  ^ 

Polypus  resembling 'condyle-  rare  cascs  caii  enlarge  the  osse- 
'"'''**■  ous  meatus  by  pressure.     If  the 

polypus  projects  out  of  the  meatus  the  secretion  quite 

1  Case  by  Borberg,  A./.  0.,  vii.,  S.  55. 


THE    TYMPANUM.  125 

frequently  produces  ulceration  on  its  club-shaped  end. 
Often  several  polypi  are  in  the  same  ear ;  it  is  less 
common  to  find  polypi  simultaneously  in  both  ears. 
Spontaneous  expulsion  of  large  polypi  several  cen- 
timeters in  length  has  occurred  in  several  cases ;  I 
myself  have  observed  one  such  case. 

The  external  form  of  polypi  is  variable.  We  find 
them  perfectly  smooth  and  club-shaped  on  their  ex- 
ternal portions,  but  most  of  these  show  a  papillary 
structure  near  their  bases ;  the  color  of  the  parts  of 
the  tumor  exposed  to  the  air  is  whitish  or  grayish 
yellow-pink.  Others  again  are  knobbed  on  their  sur- 
faces from  a  universal  papillary  structure,  and  the 
color  is  bright  red.  The  papilla  are  either  situated 
on  a  compact  base  of  tissue,  or  the  whole  tumor 'con- 
sists only  of  branching  papillae  of  all  sizes  and  forms, 
producing  sometimes  an  appearance  like  condylomata. 

The  consistency  of  most  polypi  is  soft ;  only  rarely 
is  one  seen  of  fibromatous  hardness. 

All  aural  polypi  are  covered  by  epithelium,  either 
by  a  single  or  multiple  layer  of  cylinder  epithelium, 
the  upper  layer  of  which  possesses  cilice,  or  by  a  "mul- 
tiple layer  of  pavement  epithelium,  or  by  a  mixed 
epithelium.  In  the  latter  case  the  base  of  the  tumor 
is  covered  by  a  ciliated  cylinder  epithelium  and  its 
external  end  by  a  multiple  layer  of  pavement  epitheli- 
um, arranged  as  in  the  epidermis.  The  transition  from 
the  cylinder  to  the  pavement  epithelium  is  gradual. 

According  to  their  histological  structure  three  spe- 
cies of  polypi  can  be  distinguished:  mucous  polypi, 
fibromata,  and  myxomata. 

The  mucous  polyjn  are  the  most  common  and  are 
exactly  similar  to  mucous  polypi   of  other  cavities, 


126  PATHOLOGY  OF   THE  EAR. 

being  produced  by  a  hyperplasia  of  the  tympanic 
mucous  membrane. 

The  glands  which  exist  in  them  are  tubular  inver- 
sions of  the  epithelium  into  the  tissue  of  the  polypus: 
they  are  hyperplastic  formations  of  the  glands  of  the 
tympanic  mucous  membrane,  which  have  been  de- 
scribed by  Von  Troeltsch  and  Wendt.  With  these  tu- 
bular glands  the  cystic  cavities  described  by  Meissner 
are  almost  always  found ;  the  cysts  being  lined  with 
an  imperfect  epithelium,  and  filled  with  a  mucous 
fluid  in  which  loose  epithelial  cells  and  mucous  cor- 
puscles are  suspended.  According  to  Steudener  they 
are  to  be  regarded  as  retention-cysts,  produced  from 
the  tubular  glands.  It  is  possible,  however,  that 
they  are  produced  by  the  union  of  the  interpapillary 
spaces  in  the  same  manner  that  they  were  observed 
to  be  produced  on  a  papillary  polypus  of  the  portio 
vaginalis  uteri  by  Rindfleisch.^ 

Fibromata  are  developed  from  the  periosteal  layer 
of  the  tympanic  mucous  membrane,  and  are  similar 
to  the  fibromata  which  develop  as  naso-pharyngeal 
polypi  from  the  periosteum  of  the  base  of  the  skull. 
They  are  dense  and  fixed,  of  a  pale  color  on  account 
of  the  paucity  of  developed  blood-vessels,  are  always 
covered  by  a  multiple  layer  of  pavement  epithelium, 
and  are  never  very  markedly  papillary.  Into  their 
epithelial  covering  small  papillae,  generally  single  but 
occasionally  double,  project,  like  the  papilla  of  the 
cutis.  Tubular  glands  and  cysts  are  not  found  in 
these  fibromata.  Their  structure  consists  of  a  firm 
connective  tissue  with  numerous  spindle  or  star- 
shaped  connective-tissue  corpuscles,  the  processes  of 

1  Patholog.  Histologic,  S.  62. 


THE    TYMPANUM.  127 

which  anastomose  with  each  other.  The  intercellu- 
lar substance  is  sometimes  perfectly  homogeneous, 
sometimes  grossly  fibrillary.  In  the  latter  case  the 
fibrillar  are  generally  arranged  in  bundles  interlacing 
with  each  other. 

The  existence  of  the  very  rare  polypoid  myxomata 
of  the  tympanic  mucous  membrane  was  first  con- 
firmed by  Steudener,  in  a  polj-pus  arising  by  a  broad 
base  from  the  tympanum  of  a  boy  seventeen  years 
old.  It  had  been  extirpated  by  me,  and  from  its  ex- 
ternal appearance  seemed  to  be  perfectly  gelatinous. 
Its  epithelial  covering  consisted  of  a  multiple  layer 
of  pavement  epithelium  into  which  flat  papilla?,  like 
those  of  the  cutis,  projected. 

"  The  stroma  consisted  of  a  perfectly  homogeneous 
gelatinous  tissue  crossed  by  an  anastomosing  net- 
work of  spindle  and  star-shaped  cells ;  very  fine 
fibrillin  were  also  found,  which  in  some  parts  ac- 
companied the  rows  of  cells,  in  other  parts  formed  a 
wide-meshed  network  through  the  gelatinous  tissue. 
On  the  surfice  of  the  tumor,  and  also  in  the  neio-h- 
borhood  of  the  blood-vessels,  these  fibrilloe  were  es- 
pecially numerous,  in  the  former  case  in  layers 
parallel  to  the  surface  of  the  tumor,  in  the  latter 
case  in  layers  concentric  to  the  blood-vessels." 

In  the  gelatinous  tissue,  in  the  meshes  of  the  net- 
work formed  by  the  cells  and  fibrilla?,  a  moderate 
number  of  round,  granular  cells  with  a  simple  round 
nucleus,  of  the  size  and  appearance  of  lymph-cor- 
puscles, were  found ;  in  certain  spots,  these  were  col- 
lected together  in  small  groups.^ 

To  explain  the  existence  of  this  form  of  tumor  it 

1  Steudener,  I.  c. 


128  PATHOLOGY  OF  THE   EAR. 

should  be  remembered  that  the  foetal  tympanum  con- 
tahis  mucous  tissue,  which  gradually  undergoes  a 
retrograde  metamorphosis  after  birth.  Residues  of 
this  tissue  may,  on  the  occurrence  of  purulent  catarrh 
of  the  middle  ear,  which  is  extremely  common  in 
new-born  children,  become  irritated  and  increase  in 
size,  thus  producing  a  polypoid  tumor. 

It  should  be  noticed  here  that  a  polypus  arising 
from  the  promontory  and  projecting  into  the  meatus, 
may  be  entirely  shut  off  from  the  tympanum  by  a  cica- 
tricial adhesion  of  the  edges  of  the  perforation  of  the 
membrana  tympani  with  the  labyrinth-wall  around 
the  insertion  of  the  polypus. 

Hinton  found  a  small  fibroma  arising  from  the 
chorda  tympani  and  Professor  Koeppe  informs  me 
that  he  has  seen  a  gumma  on  the  same  spot. 

Cholesteatoma,  pearl-tumor,  has  already  been  fully 
described  on  page  22. 

Exostoses  occur  on  the  tympanic  walls  and  on  the 
ossicles.  On  the  floor  of  the  cavity  and  on  the  lower 
edge  of  the  promontory,  they  occur  as  normal  forma- 
tions, like  osteophytes,  in  the  form  of  sharp  points 
and  osseous  bridges ;  but  they  are  also  found  in  these 
shapes  as  pathological  formations 
on  other  parts,  as  the  promontory, 
the  neighborhood  of  the  fenestra 
rotunda  and  eminentia  pyramid- 
alis,  where  they  are  the  results  of 
chronic  periostitis.  If  the  drum- 
Fig.  62.  membrane  has  been  partially  de- 
Exostoses  of  the  Laby-  stroyed,   tlicy  may  be   visible   on 

rinth-wall,    visible    tlirough    .  .  „  ,      .  ■, 

a  perforation  of  the  Drum-    mspectlOn.  OsSCOUS     bridgCS    are 

membrane.  souietimcs     fouud     bctwceu     the 

eminentia  pyramidalis  and  fenestra  ovalis. 


THE    TYMPANUM.  120 

Zaufal  describes  and  figures  an  extensive,  com- 
pact exostosis,  arising  from  the  posterior  wall  of  the 
tympanum  and  the  wall  of  the  fossa  jugularis,  which 
had  closed  the  fenestra  rotunda  and  produced  partial 
absorption  of  the  sulcus  pro  membrana  tjnnpani.^ 

Hyperostosis  of  the  fenestra  rotunda  produces  a 
slit-like  narrowing  and,  in  its  highest  degrees,  com- 
plete closure  of  this  opening,  as  was  well  known  to 
the  older  observers.^  If  the  hyperostosis  of  the  tym- 
panic walls  is  equally  distributed  a  marked  narrowing 
of  the  tympanum  results. 

Cysts.  A  retention-cyst  lined  with  epithelium  and 
filled  with  rhombic  tables  of  fat-crystals  has  been  de- 
scribed by  me  ;  ^  it  was  apparently  developed  from  a 
tubular  mucous  gland  of  the  tympanic  mucous  mem- 
brane. Politzer'^  has  seen  cyst-like  formations  aris- 
ing from  the  mucosa  of  the  drum-membrane,  "  con- 
sisting of  a  sack  with  thick  fluid  contents."  Toynbee 
and  Hinton  have  described  cases  of  sebaceous  tumors 
or  dermoid  cysts,^  containing  hairs. 

Epitlielial  cancer,  arising  primarily  from  the  tym- 
panum, is  extremely  rare.^ 

Osteosarcoma  of  the  tympanum  reaching  into  the 
meatus  has  been  observed  by  Wilde,"  Toynbee,^  and 


1  A.f.  O..  ii.,  S.  48. 

2  Cassebohm,  De  Aiire  Humana,  Halae,    1734,   S.   39.     Cotunni,   De 
Aquretluctu,  Viennse,  1774,  S.  132. 

^  A.f.  0.,  i.,  S.  205. 
4  Ykle  A.f.  0.,  v.,  S.  216. 

^  Transactions  of  the  Patliolog.  Society,  xvii.,  pp.  274,  275. 
®  Vide  page  26. 

'  Pract.   Bemerkungen   ilber    Ohrenheilkunde,    Uebersetzung,    S.     244, 
433. 

8  Diseases  of  the  Ear,  p.  386. 

9  Wiener  Med.  Halle,  1863,  No.  54. 


130  PATHOLOGY  OF   THE   EAR. 

Tubercle.  The  existence  of  miliary  tubercle  in  the 
tympanic  mucous  membrane  of  man  has  not  been 
proven  anatomically  with  certainty.  I  have  fre- 
quently observed  during  life  small,  gray,  miliary  nod- 
ules on  the  inflamed  and  swollen  mucous  membrane 
of  the  inner  tympanic  Avail  during  the  purulent  otitis 
of  tuberculous  children  ;  these  I  was  inclined  to  re- 
gard from  their  gross  appearances  as  tubercles.  In 
my  anatomical  investigations  I  have  as  yet  sought 
them  in  vain. 

In  the  pig  the  frequent  occurrence  of  tuberculosis 
of  the  middle  ear  has  been  confirmed  by  Sclmtz.^ 

EUSTACHIAN    TUBE. 

Wendl,  Kranklieiten  der  Nasenrachenhohle  und  des  Racliens.  (Ziems- 
se/t'.s-  Handbucli  der  Spec.  Pathologie  und  Therapie,  Band  vii.,  S.  235-323, 
1874.  Moos,  Beitrage  zur  Normalen  und  Patliologischen  Anatomie  und 
zur  Pliysiologie  der  Eustacliischen  Rohre.  Mit  18  Abbildungen.  Wies- 
baden, 1874.     Lebrbiicher  von  Toi/nbee,  Von  TroeUsch,  Gruber. 

General  Remarks. 

The  Eustachian  tube  in  man  is  closed,  when  at  rest,  by  the  slight 
contact  of  its  walls.  It  is,  however,  a  condition  of  normal  hearing 
that  the  canal  should  be  from  time  to  time  opened  in  order  that  the 
differences  of  air-pressure  between  the  tympanum  and  the  atmos- 
phere may  be  equalized  by  the  so-called  ventilation  of  the  tym- 
panum. Every  long-continued  closure  of  the  tube  at  any  point 
of  its  course  by  swelling,  collection  of  secretion,  or  insufficiency  of 
the  musculus  dilatator  tubie  sive  tensor  veli  palatini  results,  Avhen 
the  drum-membrane  is  imperforate,  in  a  gradual  absorption  of  the 
air  within  the  tympanum  ;  the  drum-membrane,  with  its  appendages, 
then  sinks  inwards,  owing  to  the  over-pressure  of  the  atmosphere, 
its  tension  is  increased,  and  a  hypertemia  ex  vacuo  occurs  in  the 
tympanic  mucous  membrane.  As  the  result  of  this  hyperamiia,  a 
transudation  or  serous  exudation  next  takes  place,  and  this  is  fre- 

1  Virdwics  Archlv,  Band  GG,  S   93. 


EUSTACHIAN  TUBE.  131 

quently  followed  by  swelling  of  the  tympanic  mucous  membrane  and 
abnormal  adhesions  between  the  drum-membrane,  its  appendages, 
and  the  tympanic  walls.  As  the  Eustachian  tube  in  children  is  ab- 
solutely wider  and  shorter  than  in  adults,  it  would  in  childhood  less 
commonly  and  easily  become  closed  were  it  not  that  the  form  of 
the  pharyngeal  orifice  in  children  is  slit-like,  while  in  adults  it  is 
widely  open  ;  and  this  foi'm  of  the  pharyngeal  orifice  furnishes  a 
predisposition  to  closure  of  the  tube  whenever  the  mucous  membrane 
of  the  naso-pharynx  is  swollen.  The  shape  of  the  pharyngeal 
orifice  is  subject  to  individual  variations ;  it  is  in  adults  by  no  means 
always  funnel-shaped,  but  often  a  triangular  or  crescentic  open  fis- 
sure ;  its  average  distance  from  the  postei-ior  end  of  the  lower  nasal 
cartilage  is,  according  to  Luschka,  7  mm.  The  width  of  the  canal 
is,  in  adults,  subject  to  very  great  individual  differences :  the  aver- 
age diameter  is,  for  the  isthmus,  2  mm.  high  and  1  mm.  wide ;  for 
tlie  pharyngeal  orifice,  8  mm.  high  and  5  mm.  wide ;  for  the  tym- 
panic orifice,  5  mm.  high  and  3  mm.  wide. 

The  mucous  membrane  of  the  canal  is  somewhat  projecting  at 
the  pharyngeal  orifice,  but  at  other  points  is,  in  the  normal  condi- 
tion, smooth,  firmly  adherent  to  the  tissues  beneath,  not  easily  torn, 
and  of  a  light  yellow  color.  The  valve  of  the  tube,  a  valve-like 
duplicature  of  the  mucous  membrane,  which  was  described  as  a  nor- 
mal formation  at  the  pharyngeal  end  of  the  canal,  by  Koellner  ^  and 
the  older  anatomists,  is  pathological,  and  due  to  a  relaxation  or 
wrinkled  swelling  of  the  mucous  membrane.  Recently  the  same 
thing  has  been  described  by  Moos  "  "as  a  prominence,  a  true  valve, 
which,  although  varying  in  different  individuals,  is  never  absent  in 
the  normal  condition." 

The  mucous  membrane  in  the  osseous  portion  of  the  tube  cor- 
responds in  its  pathological  changes  veith  the  tympanic  mucous 
membrane,  except  that  membranous  new  growths  are  less  common 
in  the  tube  than  in  the  tympanum  ;  the  membrane  in  the  cartilagi- 
nous tube,  however,  conforms,  as  a  rule,  with  the  condition  of  the 
mucous  membrane  of  the  naso-pharynx.  And  also  just  as  there 
exists  a  cystogenous,  adenoid  tissiae,  with  numerous  scattered  lymph- 
follicles  directly  beneath  the  mucous  membrane  on  the  roof  of  the 

1  Reil's  Archiv,  ii.,  S.  18. 

2  Bei/rdge  zur  Anatomie  unci  Pliysiologie  der  Eustaclmchen  Rohre, 
Wiesbaden,  1874,  S.  29. 


132  PATHOLOGY  OF   THE  EAR. 

naso-pliavvngeal  cavity,  passing  transversely  from  one  tubal  orifice 
to  the  other,  and  also  ou  the  tubal  prominence  and  in  the  cavity  of 
Eosenmiiller,  so  also  there  is  in  direct  continuity  with  this  tissue  at 
the  pharyngeal  orifice  of  the  Eustacliiau  tube  a  layer  of  cystogenous 
substance,  of  variable  thickness,  beneath  the  ciliated  cylinder  epithe- 
lium. This  adenoid  tissue  is  subject,  especially  in  childhood,  to  great 
hyperplasia,  causing  narrowing  and  closure  of  the  orifice  of  the 
tube.  In  old  age  this  same  tissue  is  subject  to  atrophy.  The  mu- 
cous membrane,  between  the  tubal  prominence  and  the  choanjB,  is 
normally  of  a  rather  paler,  more  j-ellowish  color  than  the  rest  of 
the  mucous  membrane. 

Malformations.  Congenital  absence  of  the  Eustachian 
tube  was  observed  by  J.  Gruber,^  in  one  case  associ- 
ated with  absence  of  the  meatus,  ossicula,  and  a  ru- 
dimentary development  of  the  tympanum  and  laby- 
rinth. Cases  of  congenital  obliteration  and  stenosis 
are  also  very  rare ;  one  case  is  recently  described  by 
J.  Gruber,^  which  was  associated  with  cleft  palate. 
Congenital  widening  of  the  tube  to  three  or  four  times 
its  normal  calibre  is  described  by  Cock.^  Congenital 
anomalies  of  the  tube,  in  the  form  of  angular  bends  ^ 
in  its  osseous  portion,  of  ossification-gaps  in  the  wall 
of  the  canalis  caroticus,  of  unsj'tnmetrical  position  of 
the  pharyngeal  orifices,  are  more  common. 

Hypersemia  and  Hemorrhage.  Hyperasmia  in  the  tu- 
bal mucous  membrane  occurs  of  all  degrees,  from  a 
slight  net-like  injection  to  a  uniform  scarlet  or  brown- 
red  color.  With  simultaneous  hyperasmia  of  the  pha- 
rynx, it  is  most  marked  in  the  cartilaginous  portion 

1  Vi.le  A./.  0.,  ii.,  S.  154. 

2  LeJtrbuch  der  Ohrenheilkunde,  S.  573,  with  an  illustration. 
^  Med.  Cliirurg.  Transactions,  London,  vol.  xix.,  p.  ICl. 

*  The  median  wall  of  the  os^eoiis  tube  may  show  depressions  two  mm. 
or  more  in  depth,  and,  as  the  lateral  wall  does  not  follow  this  cui'vature, 
a  sudden  dilation  of  the  tube  at  these  points  is  then  produced. 


EUSTACHIAN   TUBE.  133 

of  the  tube,  gradually  diminishing  in  intensity  towards 
the  tympanic  orifice.  Just  the  opposite  is  the  case 
with  simultaneous  hyperaemia  of  the  tympanum.  If 
the  hypenemia  of  the  pharynx  extends  into  the  car- 
tilaginous tube,  rhinoscopic  examination  during  life, 
and  also  the  autopsy,  often  show  the  ostium  pharyn- 
geum  tuboB  surrounded  by  a  tissue  of  enlarged  veins, 
which  can  be  followed  into  the  tube.  Dissection,  in 
such  cases,  shows  also  a  decided  injection,  with  in- 
creased secretion,  higher  up  the  tube.  Not  infre- 
quently a  decided  hyperasmia  of  the  pharynx  will  be 
found  to  cease  just  at  the  edge  of  the  tube. 

Hemorrhages  are  found  in  the  form  of  ecchymoses 
in  the  tissue  of  the  mucous  membrane  and  as  large 
Hat  extravasations.  If  the  exudation  is  situated  at 
the  ostium  pharyngeum  the  opening  may  be  closed 
as  with  a  plug.  Gray  and  grayish-black  pigmenta- 
tions of  the  pharyngeal  mucous  membrane  ai'e  some- 
times seen  to  extend  into  the  cartilao-inous  tube. 
Large  amounts  of  coagulated  blood  are  sometimes 
seen  in  the  tube  after  fracture  of  the  base  of  the  skull 
and  after  haemoptysis  and  hasmatemesis. 

Inflammation.  The  catarrhal  inflammation  of  the 
Eustachian  tube  is  characterized  by  hyperaemia,  in- 
creased secretion  and  swelling  of  the  mucous  mem- 
brane. An  abundant  collection  of  mucous  secretion 
is  found  very  often  on  dissection,  not  unfrequently 
so  much  that  it  appears  to  fill  the  whole  calibre  of 
the  tube.  In  this  mucus  many  loose  ciliated  epithe- 
lial cells  are  mixed.  If  the  mucus  is  thick  and  ad- 
hesive it  may  form  distinct  masses  which  project  from 
the  pharyngeal  orifice  as  the  mucous  masses  do  from 
the  OS  uteri  j  such  masses  may  also  firmly  close  the 


134  PATHOLOGY  OF   THE  EAR. 

osseous  tube  when  the  cartilaghious  tube  is  empty. 
These  masses  are  of  a  jelly-like  consistency  and  may 
be  connected  with  similar  masses  in  the  tympanum. 

The  cause  of  the  swelling  in  the  mucous  membrane 
is  hyperoemia  and  serous  infiltration,  and  also  an  in- 
crease in  the  lymph-like  elements  of  the  subepithelial 
tissue  (cellular  infiltration)  which  are  most  numerous 
at  the  pharyngeal  end  of  the  canal.  By  a  specially 
large  collection  of  these  cells  at  certain  spots,  hyper- 
plasia of  the  gland  follicles,  a  granular  appearance  of 
the  mucous  membrane,  is  produced.  There  is  also  in 
chronic  cases  a  marked  projection  and  wrinkling  of 
the  mucous  membrane  perpendicular  to  the  axis  of 
the  canal,  with  hypertrophy  of  the  glandular  layer 
and  thickeninor-  of  the  submucous  connective-tissue. 

o 

Great  swelling  is  found  most  commonly  at  the  ostium 
pharyngeum,  which  is  then  changed  to  a  mere  slit ; 
higher  up  the  tube  it  is  more  rare  and  is  leas-t  com- 
mon in  the  osseous  tube.  In  the  latter  situation, 
however,  a  granular  appearance  of  the  mucous  mem- 
brane caused  by  the  formation  of  small  cells  may  oc- 
cur, with  simultaneous  analogous  changes  in  the  tym- 
panic mucous  membrane,  or  the  layer  of  submucous 
connective  tissue  may  be  hypertrophied. 

The  existence  of  a  genuine  croupous  inflammation 
in  the  mucous  membrane  of  the  tube  during  croup  of 
the  larynx  and  pharynx  has  been  certainly  proved 
by  Wcndt.i 

In  variola,  according  to  the  same  author,  peculiar 
changes  of  the  epithelium  with  the  formation  of  cavi- 
ties of  variable  size  and  form  and  filled  with  pus  cells, 
take  place   very  commonly  at  the  pharyngeal  orifice 

1  Archiv  der  Heilkunde,  xi.,  S.  2(31. 


EUSTACHIAN   TUBE.  135 

and  less  commonly  higher  up,  along  the  lower  third 
of  the  tube. 

Traumatic  inflammations  of  the  Eustachian  tube 
sometimes  occur  after  surgical  operations  in  the  naso- 
pharynx, from  incisions  into  the  tubal  orifice  during 
resection  of  the  upper  jaw,  etc. 

Secondary  changes  of  the  tubal  cartilage,  in  the 
form  of  small  spots  of  ossification,  have  been  described 
by  Moos.^ 

Calcifications  of  the  tubal  cartilage  also  occur  with 
chronic  inflammation  of  the  middle  ear. 

Ulceration  at  the  ostium  pharyngeum  and  extend- 
ing from  here  into  the  lower  end  of  the  cartilaginous 
tube  is  found  in  syphilis,  tuberculosis,  scrofula,  diph- 
theritis,  and  variola.'^  I  have  frequently  observed  with 
the  rhinoscope  on  the  tubal  prominence  and  at  the 
entrance  of  the  pharjaigeal  orifice  small,  round,  super- 
ficial/o?/icw?«r  ulcerations,  the  result  of  purulent  fol- 
licular catarrh  of  the  naso-pharynx.  In  caries  of  the 
temporal  bone  with  destruction  of  the  osseous  tube 
ulcers  from  erosion  are  seen  on  the  ostium  pharyn- 
geum if  the  foetid  pus  flows  into  the  pharynx  in  large 
quantities.  The  ulcers  in  variola  are  always  super- 
ficial, usually  of  a  round  form,  more  common  on  the 
sides  than  on  the  floor  and  medial  surface  of  the 
pharyngeal  orifice,  but  they  may,  however,  change 
the  whole  ostium  pharyngeum  into  a  flat  ulcerated 
surface.  They  rarely  extend  to  the  lower  third  of 
the  cartilaginous  tube. 

1  I.  c,  p.  49. 

2  According  to  Seidl  the  ulcerations  of  typlius  may  occur  in  the  tube. 
Wiener  Med.  Wochenschrift,  1852,  Nos.  2,  5,  6.  Ueber  den  Einjluss  des 
Catheterismus  der  Eusl.  Rohre. 


136  PATHOLOGY  OF   THE  EAR. 

The  ulcers  in  S3'phili.s  and  tuberculosis  which  ex- 
tend from  the  pharyngeal  mucous  membrane  are 
much  deeper,  reaching  the  cartilage  itself  and  even 
penetrating  its  substance.  On  the  edges  and  in  the 
neighborhood  of  tuberculous  ulcerations  of  the  tubal 
prominences  Wendt^  has  found  formations  of  fresh 
miliary  tubercles. 

An  extensive  tuberculous  ulceration  which  I  have 
preserved  in  my  collection,  taken  from  a  man  thirty- 
three  years  old,  extends  to  the  middle  line  of  the 
fornix  and  the  posterior  pharyngeal  wall,  involves 
the  cavity  of  Rosenmiiller,  which  is  changed  into  a 
large  excavation  twice  as  deep  as  the  cavity  on  the 
opposite  side,  and  has  destroyed  the  greater  part  of 
the  tubal  prominence.  The  mucous  membrane  of 
the  lower  portions  of  the  tube  was  hypera^mic  and 
swollen,  but  without  ulceration.  In  addition  there 
was  double  perforation  and  purulent  infiltration  of 
the  drum-membrane,  and  the  tympanic  mucous  mem- 
brane was  greatly  swollen,  and  infiltrated  with  pus. 
The  articulating  connections  of  the  ossicles  were 
loosened. 

Syphilitic  ulcerations  on  the  tubal  prominence  and 
at  the  entrance  of  the  pharyngeal  orifice,  with  ulcera- 
tions on  other  parts  of  the  naso-pharynx  as  the  sep- 
tum narium,  choanee,  fornix,  posterior  wall  of  the 
uvula,  can  often  be  recognized  by  rhinoscopic  exami- 
nation, where  the  usual  inspection  of  the  pharynx 
without  a  mirror  would  raise  no  suspicion  that  an 
ulcerative  process  existed. 

Higher  up  in  the  tube,  ulcerative  processes  only 
occur    with    caries    and   tumors    (epithelial    cancer), 

1  I.  c,  p.  297. 


EUSTACHIAN   TUBE.  137 

which  may  partially  or  wholly  destroy  the  osseous 
tube. 

Contraction  and  Enlargement.  Contraction  or  stenosis 
of  the  Eustachian  tube,  even  to  complete  closure, 
takes  place  from  swelling  of  the  mucous  membrane 
or  thickening  of  the  submucous  connective-tissue  in 
catarrh,  from  hyperplasia  of  the  cystogenous  tissue 
at  the  pharyngeal  orifice,  from  oedema  of  the  tubal 
prominence  during  congestion  of  the  vena  cava  supe- 
rior, from  cicatricial  formations  in  the  naso-pharynx, 
and  at  the  ostium  pharyngeum,  from  hypertrophic 
thickening  of  the  soft  palate,  by  which  the  anterior 
lip  of  the  tube  may  be  pressed  against  the  posterior 
lip,^  from  insufficiency  of  the  palato-tubal  muscles 
in  congenital  or  acquired  fissure  of  the  palate  and 
in  cleft  palate,  from  closure  of  the  ostium  pharyn- 
geum by  new  growths  in  the  naso-pharynx,  such  as 
naso-pharyngeal  polypi,  large  cysts,  cicatricial  bands, 
hyperplastic  pharyngeal  tonsils,^  great  swelling  of  the 
lower  nasal-cartilage,"  or  great  hypertrophy  of  the 

1  Von  Trooltsch,  A.f.  0.,  iv.,  S.  136. 

2  The  pharyngeal  tonsils  (glandulae  pharyngeae)  undergo,  especially 
in  childhood,  and  more  rarely  between  the  ages  of  twenty  and  thirty,  a 
hyperplasia  so  that  they  assume  a  ragged,  almost  polypoid  appearance. 
In  the  higher  degrees  of  this  hyperplasia  they  may  reach  more  tlian  a 
centimeter  above  the  upper  part  of  the  vomer  and  directly  cover  the  ori- 
fice of  the  tube.  By  compression  this  orifice  may  be  narrowed  to  a  mere 
slit.  If,  at  the  same  time,  there  is  hyperplasia  of  the  cystogenous  tissue 
of  the  tubal  proniinence,  this  prominence  appears  as  a  soft  fold  l  cm. 
thick,  and  with  a  ragged  edge  projecting  into  the  naso-pharynx.  Adhe- 
sions of  the  hyperplastic  glandula  pharyngea  with  the  tubal  prominence 
may  also  exist. 

2  The  posterior  edge  of  the  lower  nasal  cartilage  is  often  enormously 
thickened  and  lengthened  posteriorly;  it  then  appears  ragged,  notched, 
or  fringed.  It  may  then  reach  the  orifice  of  the  tube,  and  project  over 
and  partially  lie  upon  this  orifice.  The  irritation  resulting  from  this 
produces  hyperasmia  and  hypersecretion  which  extends  usually  as  far  as 


138  PATHOLOGY   OF   THE   EAR. 

palatine  tonsils.-^  Stenosis  from  hyperostoses  and 
exostoses,  with  or  without  osteosclerosis  of  the  skull, 
or  from  new  connective-tissue  growths  at  the  tym- 
panic orifice,  as  in  caries  or  hyperplastic  catarrh  of 
the  tympanum,  is  much  less  common. 

Stenosis  in  the  middle  portion  of  the  canal  appears 
to  be  extremely  rare.  It  is  in  practice,  from  inexact 
observation,  thought  to  be  much  more  common  than 
it  is  in  reality.  Not  infrequently  an  angular  bend  in 
the  course  of  the  tube  or  a  projection  of  the  carotid 
canal  into  the  osseous  tube  is  mistaken  for  stenosis, 
on  attempting  to  pass  a  bougie.  Real  strictures,  in 
the  sense  in  which  urethral  strictures  are  formed  by 
thickening  and  atrophic  shortening  of  the  tissues,  ap- 
pear not  to  occur  in  the  Eustachian  tube.  In  the 
osseous  tube,  however,  contractions  from  hypertrophy 
of  the  connective-tissue  layer  of  the  mucosa,  some- 
times with  deposits  of  lime,  occur. 

Contractions  at  the  ostium  tympanicum  are  fre- 
quent in  otitis  media,  produced  by  hypertrophic  mu- 
cous membrane  which  forms  a  fold  or  valve-like  elon- 
gation of  the  tissue,  or  else  by  a  new  growtli  of  con- 
nective-tissue, which  also  fills  the  anterior  part  of  the 
tympanum  ;  this  new  tissue,  when  of  recent  growth, 
is  succulent  and  red,  when  old  is  grayish  white  and 
firm.  Thread-like  bridges  of  tissue  also  occur  across 
the  ostium  tympanicum  (Von  Troeltsch,^  Magnus^), 

the  osseous  tube  (Von  Trocltsch,  A.f.  O.,  iv.,  S.  139).  Cystogenous 
tissue  exists  nornially  in  the  nuieous  membrane,  whicli  projects  from  the 
lower  nasal  cartilage. 

1  In  extreme  hypertrophy  of  the  palatine  tonsils  the  arcus  pharyngo- 
palatinus,  or  even  the  whole  palate,  may  be  pressed  against  the  ostium 
pharyngeum.     (This  is  denied  by  Wendt.) 

2  A.  f.  0.,  iv.,  S.  111. 

3  A.'/.  O.,  vi.,  S.  258. 


EUSTACHIAN   TUBE.  139 

An  osseous  stricture  of  the  tube,  three  mm.  long, 
and  one  cm.  below  the  ostium  tympanicum,  was  seen 
and  figured  by  Toynbee.^  A  bristle  could  scarcely  be 
passed  through  it. 

The  canalis  caroticus  may  project  so  far  into  the 
osseous  tube  as  to  almost  close  its  calibre.  I  have 
also  frequently  seen  the  carotid  artery  separated  from 
the  tube  merely  by  a  thin,  transparent  lamella  of 
bone. 

In  atrophy  of  the  mucous  membrane  of  the  naso- 
pharynx, the  ostium  pharyngeum  appears  unusually 
wide  open  and  deep.  The  tubal  prominence  then 
projects  very  much,  and  from  the  thinning  of  its  mu- 
cous covering  appears  almost  bare. 

Acquired  enlarcjement  of  the  canal  throughout  its 
whole  extent  is  frequent  in  connection  with  sclerosis 
of  the  tympanic  mucous  membrane.  The  canal  may 
be  enlarged  to  three  or  four  times  its  normal  calibre. 
Partial  enlargement  in  the  osseous  portion,  due  to 
atrophy  of  the  osseous  walls,  is  found  after  chronic 
suppurations  of  the  tympanum. 

According  to  Riidinger^  in  the  bodies  of  old  per- 
sons, an  abnormal  gaping  of  the  tube  throiirjhout  its 
whole  length,  with  an  atrophy  of  the  musculus  dilata- 
tor tubge,  is  frequently  seen. 

Adhesions,  from  adhesive  inflammation  or  hyper- 
ostosis, may  occur  at  both  orifices  of  the  tube,  but 
are  rare  in  the  canal  itself  Cicatricial  adhesions  of 
the  ostium  pharyngeum  occur  from  syphilitic  ulcer- 
ations in  the   naso-pharynx.      The  cicatricial   tissue 

1  Montldfi  Journal,  August,  1850  ;  Medical  Times,  February,  1850, 
p.    143. 

2  MonatsscJirift  fur  Ohrcnheilkunde,  1868,  No.  9. 


140  PATHOLOGY  OF   THE  EAR. 

closes  the  orifice,  usually  after  destruction  of  the 
whole  limb  lis  cartilagineus  and  adhesion  of  the  palate 
to  the  posterior  wall  of  the  pharynx.  The  number 
of  these  cases  as  yet  described  is  not  large.-^  After 
diphtheria,  variola,-  and  scrofula,  cicatricial  closure  of 
the  pharyngeal  orifice  has  been  observed.  A  case  of 
the  latter  form  occurred  in  Halle  in  January,  18To;^ 

A  bo}'  twelve  years  old  died  from  stenosis  of  the  trachea  caused 
by  a  cicatrized  ulceration,  directly  above  its  bifurcation.  The  lungs 
were  free  from  tubercles.  The  naso-pharynx  was  reduced  to  the  size 
of  a  small  hazel-nut.  The  firm  cicatricial  tissue  which  closed  this 
cavity  from  the  mouth,  by  the  adhesion  of  the  soft  palate  to  the  pos- 
terior wall  of  the  pharynx  was  enormously  thick,  reaching,  close  to 
the  vertebral  column,  a  thickness  of  two  centimeters.  On  the  edge 
of  the  hard  palate  in  the  median  line  was  a  very  minute  opening 
surrounded  by  white  cicatricial  edges.  The  choante  w^ere  of  normal 
width,  the  mucous  membrane  slightly  thickened,  the  cavernous  tissue 
on  the  posterior  portion  of  the  lower  nasal  cartilage  very  much 
hypertrophied  ;  the  ostium  pharyngeum  of  the  right  tube  completely 
obliterated  by  cicatricial  tissue  ;  that  of  the  left  tube  narrowed  to 
one  millimeter;  both  drum-membranes  very  much  drawn  inwards; 
tympana  and  mastoid  cells  on  both  sides  completely  filled  with  a 
sero-mucous,  perfectly  clear  exudation.  During  life  such  a  degree 
of  deafness  existed  that  it  was  necessary  to  shout  directly  into  the 
ear. 

Adhesions  from  growths  of  conective  tissue  at  i\\e 
ostium  tympanicum  are  frequent  with  caries  of  the 
temporal  bone,  and  after  the  cessation  of  suppura- 
tion of  the  tj'mpanic  mucous  membrane.     Bridges  of 

1  Otto,  Patholog.  Anatomie,  Breslau,  1814,  S.  184.  Sellene  Beohach- 
tungen  zur  Anatomie,  etc.,  Breslau,  1816,  S.  3.  Virchow  in  Virchow's 
Archiv,   xv.,  S.  313.     J.  Gruher,  StatistiscJier  Berichf  von  ISeS. 

2  Lindenbaum,  ^./.  O.,  i.,  S.  295.  According  to  Wend t,  deep  de- 
Ptructive  processes  and  adhesions  are  not  found  in  variola.  (Krankhci- 
ten  des  Nasenrachenraums,  S.  285.) 

3  Already  published  in  Volkman's  Beilriige  zur  Chintrgie,  Leipzig, 
1875,   S.  305. 


EUSTACHIAN   TUBE.  141 

connective  tissue  within  the  tube  itself  are  found  in 
great  variety;  they  were  found  three  times  in  the 
cartilaginous  tube  by  Wendt,  and  had  already  been 
described  in  three  cases  by  Toynbee.^ 

Wever  ^  describes  an  adhesion  throughout  the  whole 
length  of  the  tube  produced  "  by  a  fibrous  substance, 
which  w^as  firmly  united  with  the  mucous  mem- 
brane." 

New  Growths.  Polypi  within  the  tube  have  been 
described  in  a  few  cases.  The  most  noteworthy  case 
is  that  of  Voltolini/  where  the  polypus  filled  the 
whole  tube  like  an  earth-worm  and  had  produced  an 
enlargement  of  its  calibre. 

Large  tympanic  polypi,  fibromata,  often  have  one  of 
their  attachments  in  the  ostium  tympanicum.  Cases 
are  also  known  where  their  only  insertion  was  in 
this  orifice.  Smaller  polypoid  tumors  frequently  oc- 
cur in  the  osseous  tube. 

In  syphilis  excrescences  like  the  pointed  condylo- 
mata are  sometimes  seen  at  the  ostium  pharj^igeum  ; 
in  miliary  tuberculosis  caseous  nodules  are  sometimes 
seen  at  the  same  spot. 

Exostoses,  in  the  form  of  osteophytes,  are  fre- 
quently found  in  the  Eustachian  tube  with  similar 
growths  in  the  tympanum. 

Foreign  Bodies.  During  the  act  of  vomiting  parti- 
cles of  food  sometimes  pass  into  the  tube.  Other  for- 
eign bodies  scarcely  ever  get  into  this  canal,  except 
those  introduced  for  surgical  purposes  and  accidentally 
left  in,  such   as  broken  bougies,  etc.      The    case    of 

^  Translation  by  Moos,  p.  221. 

2  Dbs.  Inaug.,  Freiburg,  1835,  S.  13. 

8  Virchow's  Arch.,  xxxi.,  S.  220. 


142  PATHOLOGY  OF   THE   EAR. 

Fleischmann  ^  is  well  known,  where  he  found,  during 
dissection,  a  grain  of  barley  deep  in  the  tube.  An- 
dry  ^  once  found  an  ascaris  in  the  canal. 

Pathological  Changes  in  the  Tubal  Muscles.  Fatty  degen- 
eration and  atrophy  of  the  tubal  palatine  muscles  are 
the  frequent  results  of  chronic  retro-nasal  and  tubal 
catarrhs.  In  trichinosis  the  tubal  muscles  are  con- 
stantly very  abundantly  infiltrated  with  the  parasite, 
while  the  two  tympanic  muscles  appear  to  always  re- 
main free  from  them. 

A  muscular  hypertrophy  of  the  musculus  tensor 
veli  palatini  vel  dilatator  tubse  has  been  described  by- 
Moos  '^  as  the  result  of  chronic  tubal  catarrh. 

Extensive  hemorrhagic  infarcts  also  occur  in  the 
tubal  muscles  (Zaufal). 

MASTOID    PROCESS. 

Z'tya,  Processus  Mastoideus  und  (lessen  Zellen.  Ann.  Univers.  188.  S. 
241.  Maggio,  18G4.  (Auszug  von  jT/zeiVe  in  AS'c/i»?/(/^'s  Jahrbiichern.  Bd. 
125.  Heft  i.  S.  33.)  ScJucarIze  and  Et/sell,  Ueber  die  kiinstliche  Eroff- 
nung  des  Warzenfortsatzes.  A.  f.  O.  YII.  S.  157.  1873  et  seq. 
Buck,  Diseases  of  the  Mastoid  Process.  Arcliiv  fiir  Augen-  und  Ohren- 
heilkunde,  HI.  1.  1873.  2.  1874.  Wendt,  Archiv  fiir  Heilkunde  von 
Wagner.  Xlll.     S.  424-427. 

The  lining  membrane  of  the  air-cells  of  the  processus  mastoideus, 
the  communication  of  which  with  the  tympanum  Valsalsa  first  dem- 
onstrated,'*  and  Sappey  afterwards  named  the  canalis  petromas- 
toideus,  is  a  direct  continuation  of  the  mucous  membrane  of  the 
tympanum,  and  is  subject  to  the  same  pathological  changes  as  the 
tympanic  mucous  membrane.     It  possesses,  however,  no  ciliated  epi- 

1  Linkers  Sammhnu/.  Band  ii.,  S.  183. 

2  Itard,  Krankheiten  des  Ohres,  ^^'eimar,  1822,  S.  94. 
^  I.e.,  p.  47. 

*  De  Aure  Humana,  1707,  p.  17.  According  to  Buck  the  passage  from 
the  tympanum  to  the  antrum  mastoideum  is  sometimes  double  (/.  c). 


MASTOID  PROCESS.  143 

theliiira.  In  the  antrum  mastoideum,  exactly  the  same  pathological 
condition  is  almost  always  found  as  in  the  tympanum,  while  the  rest 
of  the  mastoid  cells  may  remain  free  from  disease  or,  at  least,  the 
changes  in  them  are  not  of  the  same  intensity  and  form  as  in  the 
tympanum.  From  the  unequal  development,  and  variable  relation  of 
the  solid  to  the  spongy  osseous  substance  in  the  mastoid  process,  it 
is  sometimes  difficult  to  decide  in  a  given  case  whether  we  are 
dealing  with  a  pathological  or  physiological  appearance. 

Primary  and  isolated  disease  of  the  mastoid  occurs  but  very  rarely  ; 
secondary  disease  is  common  from  diseases  of  the  tympanum  and  me- 
atus. In  childhood  caries  and  necrosis  is  generally  confined  to  the 
mastoid  process,  while  in  the  tympanum  only  purulent  catarrh  occurs. 

Malformations.  Complete  absence  of  the  process  is 
found  together  with  other  malformations  deeper  in 
the  temporal  bone,  in  congenital  deafmutism. 

The  external  form  and  size  of  the  mastoid  process 
is  extremely  variable.  Wildberg^  found  its  point 
curved  like  a  beak,  resembling  in  appearance  the 
processus  coracoideus  of  the  scapula. 

The  size  and  form  of  the  mastoid  cells  are  subject 
to  great  variations ;  even  in  the  two  processes  of  the 
same  individual,  they  seldom  correspond.  In  six 
hundred  skulls,  HyrtP  found  that  in  three  the  occiput 
helped  form  the  cells.  The  antrum  mastoideum  is 
the  only  large  cavity,  which  is  constantly  present ; 
in  a  child  this  lies  very  superficially,  directly  behind 
and  above  the  external  meatus. 

In  the  cortical  substance  of  the  bone,  which  is 
normally  from  two  to  six  millimeters  thick,  thin  spots 
or  congenital  ossification  gaps  may  exist,  sometimes 
of  such  a  size  that  the  point  of  the  little  finger  can 

1  Versuch  einer  Annt.  Physiol.  PatJwl.  Ahliandl.  iiber  die  Gelwrwerkzeuge 
des  Menschcn.    S.  14,  note  h. 

2  Wiener  Med.  Wochenschrift,  1860. 


144:  PATHOLOGY  OF   THE  EAR. 

be  passed  into  them.  The  openings  may  be  the 
cause  of  an  emphysema  of  the  skin  behind  the  ear. 

Separation  of  the  mastoid  from  the  rest  of  the  tem- 
poral bone,  was  seen  several  times  by  Meckel. 

Hypersemia  and  Hemorrhage.  Diffuse  hypercemia  of 
the  mucous  liuing  of  the  mastoid  is  common  with  sim- 
ultaneous hypera3mia  of  the  tympanum,  and  may  be 
of  au}^  degree,  from  a  yellowish  red  to  a  bluish  black 
color. 

Hemorrhatres  are  found  in  the  form  of  hemorrhao-ic 
infiltration  of  the  mucous  membrane,  and  of  effusions 
of  blood  on  the  surface  of  the  mucous  membrane, 
especially  during  typhus,  and  after  injury,  such  as  a 
blow  on  the  head  or  fracture  of  the  skull. 

Catarrhal  Inflammation  of  the  Pneumatic  Cells  of  the  Bone. 
The  swelling  and  thickening  of  the  mucous-periosteal 
lining  of  the  antrum  and  mastoid  cells  may  comiDletely 
fill  these  cavities,  if  they  are  of  small  size.  The  mu- 
cous membrane  then  assumes  from  serous  infiltration  a 
succulent,  gelatinous  appearance,  and  the  osseous  cav- 
ities, which  in  their  normal  condition  should  contain 
air,  appear  to  be  filled  with  a  red  pulpy  mass.  The 
communication  of  the  antrum  mastoid eum  with  the 
tympanum  may  thus  be  completely  obliterated  or 
only  be  retained  through  a  narrow  slit.  Where  the 
swelling  is  of  a  lesser  degree  the  unoccupied  space 
may  be  wholly  or  partially  filled  with  exudation, 
either  serum,  mucus,  or  pus.  In  most  cases  the 
tympanum  is  at  the  same  time  inflamed,  but  an  in- 
dependent inflammation  may  occur  in  the  cells  with- 
out extending  to  the  tympanum  and  without  perfora- 
tion of  the  drum-membrane.  From  an  oral  com- 
munication I  have  learned  of  a  dissection  of  a  case  of 


MASTOID  PROCESS.  145 

Professor  Zaufal's  in  which  an  isolated  suppuration  in 
the  mastoid  cells  took  place  without  caries,  and  with- 
out extending  to  the  tympanum,  and  led  to  phlebitis 
of  the  sinuses  and  death. 

Wendt  found,  in  a  case  of  croup  of  the  whole  mid- 
dle ear,  which  came  on  during  variola,  true  croupous 
membrane  also  in  the  mastoid  cells,  together  with 
abundant  cellular  infiltration  of  the  connective-tissue 
vstroma  of  the  mucous  membrane. 

As  the  result  of  chronic  catarrhal  inflammation 
within  the  cells,  pseudo-membranes  are  often  formed 
by  which  the  communication  with  the  tympanum  is 
closed.  These  pseudo-membranes,  by  shutting  in  a 
number  of  the  osseous  cells,  may  produce  large  cystic 
cavities  filled  with  a  serous  or  mucous  contents.  In 
these  new  formed  membranes  calcifications  and  ossifi- 
cations may  take  place  just  as  in  the  membranes 
within  the  tympanum.  From  the  retention  of  pus  in 
the  mastoid  cells  crystals  of  cholesterine  may  be 
formed,  often  in  large  masses,  together  with  granu- 
lar corpuscles,  fluid  fat,  and  detritus. 

Periostitis  Externa.  The  external  periosteum  of  the 
mastoid  is  sometimes  attacked  by  primary  inflamma- 
tion without  the  cavities  of  the  middle  ear  being  dis- 
eased. In  these  cases  pus  may  collect  between  the 
periosteum  and  the  bone,  superficial  necrosis  of  the 
cortical  substance  may  follow,  the  periosteum  after 
being  loosened  may  rupture  and  a  subcutaneous  ab- 
scess result.  The  periostitis  may  extend  to  the  pos- 
terior upper  wall  of  the  meatus,^  which  then  always 
shows  during  life  redness  and  swelling. 

Such  a  primary  periostitis  externa  is  rare  compared 

^  Preparation  in  the  Collection  of  Professor  Zaufal. 


146  PATHOLOGY   OF   THE  EAR. 

with  the  great  frequency  of  secondary  periostitis  as- 
sociated with  caries  and  necrosis  of  the  mastoid  cells. 

The  separation  of  the  periosteum  from  the  bone  by 
a  collection  of  pus,  unless  extensive,  does  not  always 
lead  to  necrosis. 

Suppurating  Ij^mph-glands  over  the  mastoid  pro- 
cess, glandulse  subauriculares,  with  fistula  beneath 
the  skin,  should  not  be  confounded  with  periostitic 
abscesses.  Suppuration  of  the  parotid  may  produce 
fistuloe,  which  may  extend  even  to  the  mastoid  region, 
without  the  bone  becoming  affected  by  the  suppura- 
tive process. 

Caries  and  Necrosis  is  more  common  in  the  mastoid 
than  in  any  other  part  of  the  temporal  bone.  It  is 
most  frequent  in  childhood,  on  account  of  the  ana- 
tomical relations  of  the  bone,  which  are  highly  favor- 
able to  the  retention  and  consequent  inspissation  and 
putreftiction  of  the  pus  formed  in  suppurative  inflam- 
mation of  the  mucous-periosteal  lining  of  the  mastoid 
cells.  If  during  the  inflammation  ulceration  takes 
place,  the  bone,  deprived  of  its  periosteum,  is  very 
soon  involved  in  the  molecular  necrosis  of  the  tissues, 
producing  caries. 

With  caries  of  the  mastoid  process  the  posterior 
wall  of  the  meatus  is  almost  always  deprived  of  its 
periosteum  and  perforated. 

Not  unfrequently,  if  large  portions  of  bone  have 
become  gangrenous  from  interference  with  their  nu- 
trition, large  perfectly  loose  sequestra  are  found  within 
a  carious  cavity  of  the  mastoid  which  is  nearly  filled 
by  granulations ;  the  cortical  substance  of  the  bone 
remains  firm.  In  such  cases  of  central  necrosis  of 
the  mastoid  the  disease  of  the  mucous  periosteal  lin- 


MASTOID  PROCESS. 


147 


ing  of  the  cells,  and  not  a  periostitis  externa,  is  the 
cause  of  the  necrosis.  If  the  putrid  pus  does  not  find 
a  sufficient  exit  into  the  tympanum  a  fistulous  open- 
ing; throusrh  the 
osseous  walls  is 
formed,  and  thus 
a  drainage-canal 
produced.  Such 
a  fistula  in  the 
cortical  substance 
may  exist  with- 
out the  skin  over 
the  mastoid  show- 
ing any  percepti- 
ble change.  Oc- 
casionally such 
an    opening    be-  ^.^  ^3 

comes  filled  with        Central  CariesNecrotica  of  the  Mastoid  Process.   Loose 
fr  in  Illations    s^Q"^^^''""!  within  the  cavlt}'.     The  cortlcalis  perfect. 

which  will  simulate  fluctuation,  and  yet  an  incision 
will  show  that  there  is  no  pus. 

These  fistulae  generally  open  through  the  skin  on 
the  external  surface  of  the  mastoid,  or  througli  the 
posterior  upper  wall  of  the  external  meatus,  less  com- 
monly through  the  lower  portion  of  the  mastoid,  when 
the  pus  may  gravitate  into  the  neck  and  lie  quite 
deep  ;  they  may,  however,  also  open  into  the  pos- 
terior or  middle  fossa  of  the  skull,  and  thus  produce 
fiital  secondary  disease,  as  meningitis  or  phlebitis  of 
the  sinuses  with  pysemia.  The  dangerous  proximity 
of  the  sinus  lateralis,  whose  osseous  wall  is  often  per- 
forated by  caries,  is  of  special  importance  in  this  con- 
nection. 


148 


PATHOLOGY  OF   THE  EAR. 


Before  the  fistulsB  break  through  the  skin,  abscesses 
form  behind  or  below  the  auricle  or  in  the  meatus. 
These  may  extend  even  to  the  middle  line  of  the 
occiput,  or  following  the  course  of  the  deep  fascia  of 

the  neck  may 
f  l^f'/^  even    r  e  a  c  h 

the  p  1  e  u  r  a. 
Minute  se- 
questrse  may 
disappear 
very  slowly 
by  resorption 
through  the 
granulations. 
The  presence 
of  sutures  on 
the  sequestra 
often  deter- 
mine  exactly 
the  locality 
from  w  h  i  c  h 
the  bone  has 
been  thrown 
off.  After  the  expulsion  of  a  sequestrum  through 
the  fistulce,  or  after  its  removal  artificially,  the  natural 
healing  often  takes  place  wonderfully  rapidly  if  the 
individual  is  free  from  dyscrasioB,  the  whole  cavity 
in  the  mastoid  filling  with  granulations  which  are 
gradually  transformed  into  ossified  connective  tissue 
(eburnation),  and  a  deeply  sunken  osseous  cicatrix  is 
left  behind.  In  other  cases  the  walls  of  the  patho- 
logical cavity  and  of  the  fistulous  canal  become  cov- 
ered  with   perfectly    smooth,  yellowish-white    mem- 


Fig.  64. 

Loose  Sequestrum  in  the  Mastoid  Process  seen  through  a 
large  carious  opening  (h)  in  the  Corticalis.  At  (a)  is  a  cari- 
ous opening  in  the  posterior  wall  of  the  meatus  communicat- 
ing with  the  cavity  of  the  mastoid.  At  (c)  is  a  carious  open- 
ing on  the  lower  side  of  the  pars  mastoidea.  (From  Kuh, 
"  Klinische  Beitrage,"  etc.,  Breslau,  1847.) 


MASTOID  PROCESS.  149 

brane  resembling  mucous  membrane,  which  prevents 
the  complete  obliteration  of  the  cavity.  The  open- 
ing in  the  skin  in  such  a  case  becomes  closed  by  a 
black  hard  mass,  not  unlike  cerumen,  which  furnishes 
a  natural  protection  against  external  injuries.  Micro- 
scopic examination  shows  these  black  masses  to  con- 
sist of  epithelium,  tables  of  cholesterine,  and  de- 
tritus. 

If  exfoliation  of  a  large  piece  of  bone  does  not  take 
place  the  disease  is  very  much  prolonged,  and  the 
mastoid  process  may  be  by  degrees  completely  or 
partially  lost.  Krukenberg  ^  first  called  attention  to 
the  fact  that  the  bone  may  be  replaced  sometimes  by 
a  soft,  uniform,  caseous  mass,  which  can  be  easily  cut 
by  the  knife  (caseous  degeneration).  At  the  same 
time  the  mastoid  process  may  appear  swollen  exter- 
nally owing  to  an  oedema  of  the  skin. 

Eburnation  or  sclerosis  is  a  common  result  of  chronic 
inflammations  of  the  middle  ear,  especially  of  the 
purulent  variety ;  it  occurs  at  all  ages,  even  in  the 
earliest  childhood.  The  osseous  air-cells  become 
gradually  narrower  and  narrower,  and  finally  disap- 
pear entirely ;  the  diploe  between  the  tabula  externa 
and  interna  becomes  filled  with  a  mass  of  bone,  and 
the  cortical  substance  is  thickened  by  a  deposit  of 
bone  on  its  external  surface. 

Sclerosis  of  the  mastoid  is  also  found  without  any 
indications  of  previous  inflammation  of  the  middle 
ear.  This  is  seen  especially  often  in  extreme  old  age 
and  after  constitutional  syphilis. 

Fracture.  In  fractures  of  the  skull  the  fissure  may 
pass  through  the  mastoid  process  and  the  posterior 

1  Jahrbiicher  der  Ambulatorischen  Klinik  zu  Halle,  Bd.  ii.,  S.  214. 


150  PATHOLOGY  OF   THE  EAR. 

upper  wall  of  the  meatus,  without  injuring  the  drum- 
membrane. 

New  Growths.  The  lymph  glands  lying  over  the 
mastoid  process  may  become  inflamed,  increase  in 
size,  and  form  a  well-marked  lymphomatous  tumor. 
The  inflammation  of  these  glands  may  occur  Avith  or 
after  acute  exanthemata  and  is  sometimes  very  acute, 
accompanied  by  fever  and  very  severe  pain.  The 
tumor  may  reach  a  large  size  —  I  have  seen  one  as 
large  as  the  fist,  —  is  hard  and  extremely  sensitive  to 
the  slightest  touch.  The  skin  covering  it  may  be  at 
the  same  time  inflamed  and  infiltrated. 

Arnemann  reports  that  he  has  frequently  seen  con- 
cretions of  a  chalk-like  consistency  in  the  mastoid 
cells  during  syphilis. 

Polypi  often  arise  from  the  point  where  the  tympa- 
num passes  into  the  mastoid  cells.  In  the  cells  them- 
selves polypoid  growths  of  the  mucous  membrane  are 
also  found,  usually  of  small  size  but  sometimes  in  large 
numbers. 

That  fibrous  poljqw  originating  in  the  mastoid  cells 
'•  sometimes  appear  externally  behind  the  auricle 
through  openings  formed  by  exfoliation  of  carious 
bone,"  as  Josef  Gruber  asserts,^  I  have  never  yet 
satisfied  myself  Possibly  such  were  confounded  with 
malignant  tumors. 

Cholesteatoma  has  its  most  common  origin  in  the 
antrum  mastoideum.^ 

Epithelial  cancer  can  occur  primarily  in  the  mastoid 
process,  beginning  with  darting  pains  and  a  red,  ex- 
tremely hard  swelling  of  the  mastoid.  After  incision 
or  spontaneous  rupture  a  foul  ulcer  is  formed  which 

1  Lehrhuch,  S.  593.  ^  pr^v/e  p.  23. 


THE  INNER  EAR.  — AUDITORY  NERVE.  151 

rapidly  becomes  deep  and  gives  rise  to  frequently 
recurring  hemorrhages.  After  some  months  the  hard 
infiltration  of  the  neighboring  lymph-glands  extends 
to  the  lymph  glands  in  the  parotid  which  lie  in  front 
of  the  auricle. 

THE    INNER    EAR.  —  AUDITORY    NERVE. 

T.  C.  Miirer,  De  Causis  Cophoseos  Surdo-Mutorum  Indagata  Difficili- 
bus.  Comment,  brevis  Sectionibus  Cadaverum  ut  Plurimum  Illustrata. 
C.  tab.  lithogr.  HaffnisE,  1825.  Saissy,  Essai  surles  Maladies  de  I'Oreille 
Interne,  1827.  Translated  by  FiVs/er.  Ilmenau,  1829.  (Deals  chiefly  with 
Diseases  of  the  Middle  Ear.)  Plainer,  De  Auribus  Defectivis.  Diss. 
Inaug.  Anat.  Pathol.  Marburg,  1838  (with  illustrations).  Bochdaleck, 
Einige  Patholog.  Anatomische  Untersuehungen  der  Gehbr.  and  Sprach- 
werkzeuge  von  Taubstummen,  als  Beitrag  zur  Pathologie  des  Gehbrsinns, 
1839.  (Abdruck  in  S'cAma/z,  Beitrage.  Heft  2.  S.  124-156.)  Toijnbee,  De- 
scriptive Catalogue,  etc.  London,  1857.  p.  75.  Meniere,  Gazette  Med- 
icale  de  Paris.  1861.  p.  598.  VoUolini,  Virchow's  Archiv.  XXII.  1, 
2.  Die  Krankheiten  des  Labyrinths  und  des  Gehbrnerven.  (Abhand- 
hingen  der  Schlesischen  Gesellschaft.  Naturw.-nied.  Abth.  1862.  Heft 
1.)  Michel,  Memoires  sur  les  Anomalies  Congenitales  de  I'Oreille 
Interne.  Gaz.  Med.  de  Strassbourg,  1863.  No.  4.  Samuel  Moos, 
Plbtzliche  Taubheit.  Wiener  Med.  Wochenschrift,  1863.  Nos.  41-43. 
Politzer,  A.  i.  O.  H.  S.  86.  Ueber  Liision  des  Labyrinthes.  1867.  Hin- 
ton.  Observations  on  some  of  the  Affections  classed  as  Nervous  Deaf- 
ness. Guy's  Hosp.  Reports,  XIIL  p.  152.  1868.  Voholini,  Kopfver- 
letzung;  vollstiindige  Taubheit.  Autopsie.  M.  f.  O.  1869.  S.  109. 
Gruber,  Lehrbuch  der  Ohrenheilkunde  1870.  S.  613-621.  A.  BiHtcher, 
tJeber  die  Veranderungen  des  Labyrinths,  etc.,  in  einem  Fall  von 
Fibrosarcom  des  Nerv.  Acusticus.  Archiv.  f.  A.  u.  O.  Bd.  11.  2  Abth. 
See  also  A.  f.  O.  VL  S.  279.  1871.  S.  Moos,  Archiv.  f.  A.  u.  O.  XL 
S.  24 ;  in.  S.  84  ;  Y.  S.  245.  Yirchow's  Archiv.  Bd.  69.  Heft.  2,  S. 
313,  1877. 

Primary  diseases  of  the  ultimate  structures  of  the  acoustic  nerve, 
and  of  the  osseous  capsule  of  the  labyrinth,  appear  to  be  very  much 
less  common  than  diseases  of  the  middle  ear.  "Whether  this  is  in 
reality  the  fact,  or  whether  this  iufrequency  is  only  specious  on  ac- 
count of  the  concealed  position  and  difficulty  of  examination  of 
these  structures,  must  remain  for  further  investigation.^ 

1  Deiters    (JJntersuchungen  iiber  die   Lamina   Spiralis  Memhranacca, 


152  PATHOLOGY  OF  THE  EAR. 

Secondary  disturbances  in  tlie  circulation  and  nutrition  of  the 
labyrintli  during  disease  of  tlie  middle  ear,  and  of  the  brain,  have 
been  often  recognized.  The  theory  that  the  nutrition  of  the  laby- 
rinth is  supported  only  by  the  exclusive  vascular  system  of  the 
arteria  auditiva  interna,-^  a  theory  which  was  used  to  explain  the  ap- 
parent infrequency  of  pathological  changes  in  the  labyrinth,  has  been 
rendered  doubtful  by  the  recent  discovery  of  a  direct  connection 
between  the  vascular  system  of  the  middle  ear,  and  that  of  the  laby- 
rinth through  the  inner  wall  of  the  tympanum.  From  the  exami- 
nation of  cross-sections  through  the  jaromontory,  Politzer  ^  claims  to 
have  satisfied  himself  of  such  a  direct  vascular  connection  between 
the  tympanum  and  labyrinth.  Further  confirmation  of  this  fact,  so 
far  as  it  relates  to  a  connection  between  the  vascular  systems  other 
than  through  the  capillaries,  is  yet  wanting. 

lienle  classifies  the  labyrinth  of  the  ear  under  the  pseudo-lymph 
spaces.  According  to  Hasse,  the  endolymphatic  cavity  is  in  con- 
nection through  the  aqujeductus  vestibuli  (ductus  endolymphaticus), 
with  the  liquor  cerebralis,  while  the  perilymphatic  cavity  is  appar- 
entlv  in  connection  through  the  aquteductus  cochleae  (ductus  peri- 
lymphaticus),  with  the  jugular  lymph-system.  Schwalbe,^  on  the 
coutrarv,  saw  the  space  between  the  osseous  and  membranous  laby- 
rinth fill  itself  fi-om  the  subarachnoid  cavity  through  the  porus  acus- 
ticus  internus. 

The  vena?  auditivce  interme,  which  pass  through  the  porus  acus- 
ticus  internus  with  the  arteria  auditiva  interna,  and  the  nervus 
acusticus,  empties  its  blood  into  the  lower  end  of  the  sinus  petrosus 
inferior  or  of  the  sinus  lateralis.  The  vein  contained  in  the  aquce- 
ductus  vestibuli,  which  is  composed  of  branches  from  the  semicir- 
cular canals,  empties  into  the  sinus  petrosus  superior,  either  directly 
or  through  the  interposition  of  a  vena  meningea  media  (Henle). 

Bonn,  1860)  says,  p.  11  :  "That  he  very  often  found  changes  in  the 
lamina  spiralis  membranacea,  namely,  fatty  degeneration,  in  individuals 
otherwise  healthy,  and  that  in  man  it  is  only  exceptionally  that  a  per- 
fectly normal  specimen  comes  under  observation." 

1  Hyrtl  found  on  injection  of  the  arteria  auditiva  interna  and  menin- 
gea media  with  different  colored  waters,  that  the  labyrinth  only  assumed 
the  color  used  in  the  arteria  auditiva,  and  tliat  the  rest  of  the  temporal 
bone  assumed  the  color  used  in  the  arteria  meningea  media  {Vide 
Henle,  Geffisslelire.  Brnunschweig,  1876,  S.  217). 

2  A.  F.O.,  xi.,  S.  237.  ^  Med.  Centralblatt,  1869,  No.  30. 


THE  INNER  EAR.— AUDITORY  NERVE.         153 

The  nervus  acusticus  arises  in  the  medulla  oblongata  by  two 
roots,  one  of  which  comes  from  ganglion  cells  on  the  floor  of  the 
fourth  ventricle  (the  central  acoustic  nucleus,  Stieda),  the  other 
arises  with  very  thick  fibres  from  the  large-celled  ganglion  nucleus 
in  the  crus  cerebelli  ad  medullam  oblongatam  (the  lateral  acoustic 
nucleus).  This  latter  root  just  beyond  its  exit  from  the  medulla  has 
a  small  ganglion.  The  two  roots  unite  soon  into  a  common  trunk. 
The  course  of  the  acoustic  fibres  in  the  cerebellum  is  not  known ; 
according  to  Meyuert  the  fibres  of  the  roots  of  the  acusticus  cross 
each  other. 

The  membranous  tissues  of  the  labyrinth  retain  their  forms  longer 
and  better  after  death  than  is  generally  supposed.^  For  their  preser- 
vation, or  for  preparing  them  for  microscopic  examination,  the  follow- 
ing methods  are  used  : — 

(1.)  Immersion  in  absolute  alcohol  after  previous  softening  of  the 
bone  in  dilute  muriatic  acid  (Henle). 

(2.)  Immersion  in  chromic  acid  and  potass  chromate,  Midler's 
fluid. 

(3.)  Immersion  in  a  solution  of  a  substance  which  itself  becomes 
hard ;  according  to  Boettcher  glue,  according  to  Loewenberg  con- 
centrated solution  of  gum  arabie,  according  to  Klebs  glue  and  glyc- 
erine in  equal  parts. 

For  the  anatomical  recognition  of  atrophy  of  the  nerve  fibres  in 
the  ultimate  nervous  apparatus  the  reaction  with  gold  chloride  is 
used. 

For  the  examination  of  the  cochlea,  Waldeyer  -  gives  the  follow- 
ing method  of  preparation  :  ''  After  opening  the  osseous  covering  at 
several  spots  the  cochlea  should  be  laid  for  twenty-four  hours  in  a 
large  quantity  of  a  solution  of  palladium  chloride  (0.001  per  cent.) 
or  of  perosmic  acid  (0.2-1  per  cent.).  It  should  then  be  placed  in 
absolute  alcohol  for  twenty  hours  ;  then  decalcified  by  a  mixture  of 
a  solution  of  palladium  chloride  (0.001  per  cent.)  with  one  tenth 
part  of  a  solution  of  muriatic  or  chromic  acid  (^  -  1  per  cent.).  After 
decalcification  the  preparation  should  be  again  laid  in  absolute  alco- 
hol." 

CochleiB  which  have  been  hardened  in  Miiller's  fluid  can  also  be 
decalcified  with  advantage  after  the  manner  of  Waldeyer  (Steud- 
ener.) 

1  Boettcher,  A.  f.  A.  und  0.  -  Strieker's  Handbuck,  ii.,  S.  958. 


154  PATHOLOGY  OF   THE  EAR. 

Malformations.  In  aclclition  to  the  literature  of  this 
subject,  mentioned  under  malformations  of  the  ear  in 
general,  the  following  works  treat  speciallj^  of  mal- 
formations of  the  inner  ear. 

]\Iundbn,  Anatomia  Surdinati.  S.  422.  De  Labyrinth!  Auris  Content. 
P\,oeilerer,  Descript.  Foetus  Paras.,  in  Comment.  Societ.  Goetting.  IV. 
Meckel,  Handbuch  der  Patholog.  Anatomie.  Bd.  I.  /.  G.  Midler,  An- 
nalen  fiir  Ges.  Heilkunde.  1832.  (Dissections  of  the  ears  of  some  deaf- 
mutes.)  Ed.  Cock,  Med.-chir.  Transactions.  Vol.  XIX.  1837.  Thur- 
nam,  Ibid.  Nuhn,  Dissert,  de  Vitiis,  quae  Surdo-mutitati  subesse  solerit. 
Heidelbei-g,  1841.  Michel,  Mittheilung  an  die  Franzosische  Akademie. 
1855.  Helie  (Nantes),  Archiv.  Gener.  de  Med.  XII.  485.  BuM  and 
Hohrich,  Beitrag  zur  Entwicklungsgeschichte  des  Inneren  Obres,  ent- 
nommen  aus  Missbildungen  desselben.  Zeitschrift  fur  Biologie.  1867. 
Schwartze,  A.  f.  O.  V.  S.  296.  1870.  VoltoUni,  Monatschrift  f.  O. 
1870.     No.  9.     Section  des  Gehororgans  eines  Hemiccphalus. 

The  whole  laljjrinth  may  be  wanting^  or  it  may  be 
imperfectly  developed.  In  the  latter  case  certain  parts 
may  be  wanting,  as  the  semicircular  canals^  or  the 
cochlea  ;  or  certain  parts  may  be  rudimentary  ^  only  ; 
or  again  the  whole  labyrinth  may  form  a  single  cav- 
ity or  curved  canal  without  communication  with  the 
tympanum  .* 

Dissimilarity  in  the  size  and  shape  of  separate  por- 
tions of  the  labyrinths  of  different  individuals  is  very 

1  Saissy,  Uebersetzung,  S.  173.  External  ear,  drum-membrane  and 
Eustachian  tube  normally  formed  ;  tympanum  full  of  mucus.  Ossicula, 
labyrinthine  fenestra  and  all  parts  of  the  labyrinth  were  wanting. 

-  Miirer,  /.  c.  Tympanum,  vestibule  and  cochlea  normal  ;  only  the 
first  portions  of  the  semi-circular  canals  present  ;  at  the  position  where 
they  should  have  been  was  spongy  bone.  Several  cases  by  Bochdalek, 
(1.  c.  Fall  3,  4,  6).  Voltolini  (Virchoic'.f  Archiv,  xxvii.),  and  others. 
My  own  observation  in  1867,  in  a  child  with  rachitis  and  premature 
synostosis  of  the  skull. 

3  Cochlea  with  1^-2  spirals,  without  modiolus  or  lamina  spiralis ;  the 
semi-circular  canals  widened  or  narrowed,  in  their  middle  portions  im- 
passable or  ending  in  a  blind  cul  de  sac. 

*  Roederer,  Saissy. 


THE  INNER  EAR.  — AUDITORY  NERVE.  155 

common,  but  the  sliajDe  on  the  two  sides  of  the  same 
individual  is  always  the  same,  as  was  asserted  by 
Meckel  and  confirmed  by  Claudius. 

In  one  case  in  which  there  was  a  normal  develop- 
ment of  the  external  and  middle  ears  I  found  an  ab- 
sence of  the  osseous  and  membranous  labyrinths  on 
both  sides,  that  is,  the  cochleae,  vestibules,  and  semi- 
circular canals  w^ere  all  wanting.  The  trunk  of  the 
nervus  acusticus  ended  just  beyond  its  subdivision  in 
a  neuroma-like  swellino;  within  the  bone  and  was  in 
part  adherent  to  the  base  of  the  normally  movable 
stapes.  Microscopic  examination  of  these  neurama- 
tous  swellings  showed  small  nerve  fibres  crossing  each 
other  in  different  directions  and  betw^een  these  fibres 
a  small  amount  of  loose  connective  tissue.  The  pos- 
sibility of  a  malformation  being  confined  to  the  laby- 
rinth is  recognized  from  a  consideration  of  the  devel- 
opment of  this  organ,  for  the  labyrinth  is  developed 
from  the  lal)yrinthine-vesicle  in  the  region  of  the  cer- 
ebellum while  the  middle  ear  and  external  meatus  are 
formed  from  the  first  branchial  cleft  and  the  ossicula 
from  the  first  and  second  branchial  plates.  The  au- 
ditory nerve  which  eventually  unites  the  brain  and 
the  labyrinthine  vesicle  is  developed  independently. 

Congenital  Absence  of  the  auditory  nerve  is  ex- 
tremely rare  and  is  never  found  except  with  absence 
of  the  labyrinth.  The  earlier  the  arrest  of  develop- 
ment takes  place  the  smaller  is  the  meatus  auditorius 
internus  found  to  be. 

Anaemia  of  the  labyrinth,  the  anatomical  recognition 
of  which  is  very  difficult,  has  been  assumed  to  be  the 
cause  of  disturbances  of  function  in  the  ear  which  fol- 
low very  depleting  diseases  and  which  are  also  seen 


156  PATHOLOGY  OF   THE  EAR. 

in  general  anemia  without  other  pathological  changes ; 
but  it  is  still  doubtful  whether  these  aural  symptoms 
cannot  be  referred  w^ith  equal  justice  to  changes  in  the 
intracranial  circulation  and  a  consequent  imperfect 
perceptive  power  in  the  central  organ,  the  brain. 
Anaemia  certainly  results  from  contraction  (endarte- 
ritis chronica^)  and  embolus  of  the  arteria  auditiva  in- 
terna, a  branch  of  the  arteria  basilaris,  and  also  from 
aneurism  of  the  arteria  basilaris  and  carotis.  An  em- 
bolus of  the  basilaris  was  found  on  dissection  by  Prof. 
Friedreich  of  Heidelberg  to  be  the  cause  of  a  sudden 
deafness  in  one  case. 

Hypersemia  in  the  labyrinth,  of  various  degrees  of 
intensity,  from  a  net-like  injection  to  a  diffuse  red- 
ness, confined  to  certain  parts,  as  the  vestibule  ^  and 
cochlea,^  or  equally  distributed  in  all  parts  occurs,  — 

(1.)  In  some  febrile  general  diseases,  as  typhus, 
puerperal  fever,  acute  tuberculosis,  and  also  with 
poisoning  from  carbonic  oxide  gas. 

(2.)  With  acute  and  chronic  inflammations  of  the 
tympanum. 

(3.)  With  intracranial  hyperoemias  and  conges- 
tions (meningitis),  and  with  fractures  of  the  skull. 

(4.)  As  a  passive  hyperaemia  in  disturbances  of  the 
circulation,  with  disease  of  the  heart  and  emphysema 
of  the  lungs,  from  pressure  on  the  veins  of  the  neck 
by  tumors,  especially  those  arising  from  scrofula,  and 
from  the  lymph-glands,  from  pressure  by  tumors  on 
the  brain-sinuses  which  receive  the  venous  blood  of 

1  Whether  the  endarteritis  luetica  of  the  arteries  of  the  brain,  described 
by  Heubner,  also  occurs  on  the  arteria  auditiva  interna,  I  do  not  know. 

-  Hinton,  Supplement  to  Toi/nbee^s  Diseases  of  the  Ear,  p.  4G1  (in 
hereditary  Syphilis). 

3  Toynbee,  Catalogue,  No.  512  (in  constitutional  Syphilis). 


THE  INNER   EAR.  — AUDITORY  NERVE.         157 

the  labyrinth,  from  thrombus  and  phlebitis  of  the 
sinus  petrosus  superior. 

(5.)  As  the  result  of  disturbances  in  the  vaso-motor 
innervation  in  hysterical  persons. 

Hyperasmia  of  the  labyrinth  is  most  commonly  de- 
scribed in  connection  with  inflammatory  affections  of 
the  tympanum.^  From  my  own  anatomical  inves- 
tigations, I  must  add,  however,  that  even  with  the 
most  acute  inflammations  of  the  tymjDanum,  a  simul- 
taneous hyperoemia  of  the  labyrinth  was  met  with 
only  exceptionally. 

Hemorrhage.  Eccliymoses  in  the  membranous  tis- 
sues of  the  labyrinth  are  found  with  hypergemias 
in  typhus,  acute  tuberculosis,  and  variola.  Hemor- 
rhages'^ into  the  labyrinthine  cavity  and  the  mem- 
branous labyrinth  occur  with  fractures  of  the  petrous 
bone,  with  severe  contusions  of  the  skull  without 
fracture,^  with  atheroma  of  the  arteries,  with  heart 
and  kidney  affections,  with  acute  tuberculosis,  typhus, 
scarlet-fever,  measles,  and,  according  to  Toynbee,  with 
mumps  and  arthritis.  The  extravasations  produced 
by  fractures  may  become  jDurulent,  and  from  the 
evacuation  of  the  pus  through  the  porus  acusticus 
internus  may  set  up  a  basilar  meningitis.*  Deposits 
of  pigment  can  be  regarded  as  pathological  only  when 
very  marked.     In  adults,  a  slight  amount  of  pigment 

^  Hinton  alone,  I.  c,  found  it  foi'ty-one  times. 

2  Toynbee,  Catalogue,  cases  711,  738,  752. 

8  Moos  {A.  f.  A.  and  0.,  Bd.  ii.,  S.  24)  found  in  a  gun-shot  fracture 
of  the  mastoid  and  external  meatus,  together  with  purulent  catarrh  of 
the  middle  ear,  and  perforation  and  synechiaj  of  the  drum-membrane, 
an  effusion  of  blood  in  the  membranous  labyrinth,  and  a  hemorrhagic 
infiltration  of  the  perineurilemma  of  the  nerves  which  lie  in  the  lamina 
spiralis  ossea.     There  was  total  deafness. 

4  Politzer,  A.  f.  0.,  ii.,  S.  88. 


158  PATHOLOGY  OF   THE  EAR. 

is  SO  often  seen  on  the  different  parts  of  the  laby- 
rinthine tissues/  especially  in  the  cochlea,  in  cases  in 
Avhich  it  was  well  known  there  were  no  disturbances 
of  function,  that  it  is  possibl}'  a  normal  condition. 

Inflammation  and  its  Results.  The  existence  of  an  in- 
dependent and  primary,  non-traumatic  inflammation 
of  the  membranous  labyrinth  had  not  yet  been  demon- 
strated anatomically  wdth  certainty.^  In  regard  to  the 
case  of  Meniere,  described  as  a  primary  inflammation, 
'•  exsudation  sanguine,"  in  the  semicircular  canals  and 
vestibule,  it  is  doubtful  whether  it  was  anything  more 
than  a  simple  hemorrhage.  Death  is  very  rare  dur- 
ing recent  inflammations  of  the  labyrinth,  and  from 
an  accident  only  is  it  possible  to  clear  up  this  doubt 
anatomically. 

The  following  case  was  under  my  observation  dur- 
ing the  summer  of  1877,  and  afterwards  came  to  dis- 
section. It  places  the  existence  of  a  'priraary  acute 
'purulent  inflammation  of  the  labyrinth  without  sup- 
puration of  the  middle  ear  beyond  all  doubt. 

A  woman,  tliirtj-tbree  years  old,  of  delicate  constitution,  had 
aborted  on  account  of  constitutional  syphilis,  passed  through  a 
course  of  inunction,  and  remained  anaemic  afterwards.  For  some 
weeks  she  complained  of  headache  on  the  right  side,  then  of  pain 
in  the  ear,  dizziness,  staggering  gait,  violent  subjective  noises,  and 
frequent  vomiting.  Objectively  there  was  hyperfemia  of  the  right 
drum-membrane.  On  account  of  increasing  pain  in  the  ear  para- 
centesis of  the  right  drum-membrane  was  performed  without  evacu- 

1  Koelliker,  Gewehelehre  (1852),  §§  234,  235.  Lucae,  Virchow's  Archiv, 
Bd.  29,  S.  10. 

2  According  to  Heidenreicli  (Canstatt's  JahresbericJit ,  1846),  the  ex- 
istence of  an  independent  acute  inflammation  of  the  labyrinth  was  found 
on  dissection  by  Biechy  and  Batissier  (Revue  des  Special,  etc.,  Me'd.- 
chiriirg.  Juillet.  Revue  Med.,  S.  587).  The  original  article  was  not  at  my 
command. 


THE   INNER   EAR.  —  AUDITORY  NERVE.  159 

ating  any  pus.  For  some  clays  there  was  improvement,  then  an 
increase  in  the  pain  in  the  head  came  on  with  a  rapid  rise  in  the 
temperature  to  40.5  Centigrade,  and  the  usual  symptoms  of  acute 
meningitis  purulenta. 

The  autopsy  showed  diffuse  purulent  meningitis  of  the  base  and 
convexity ;  no  caries  of  the  temporal  bone,  no  purulent  deposit  on 
the  nerve  trunks  in  the  porus  acusticus  internus.  The  drum-mem- 
brane was  not  perforated,  the  puncture  having  healed  ;  the  tympanic 
mucous  membrane  was  a  little  thickened,  the  tympanum  free  from 
pus  and  of  normal  appearance.  In  the  labyrinth  —  cochlea,  vesti- 
bule, and  semicircular  canals  —  was  a  sero-purulent  fluid,  of  milky 
appearance,  which,  under  the  microscope,  showed  nothing  but  ftitty 
pus  cells.  The  vessels  of  the  semicircular  canals  were  tensely  filled 
and  tortuous,  those  of  the  ampullns  showed  the  same  conditions  in  a 
more  marked  degree,  and  in  certain  spots  small  extravasations  were 
seen.  The  utriculus  and  sacculus  were  much  swollen  and  infiltrated 
by  blood  and  pus.  The  course  of  the  labyrinthine  suppuration  into 
the  cranium  could  not  be  recognized.  Aside  from  moderate  enlarge- 
ment of  the  spleen,  all  the  organs,  both  of  the  chest  and  abdomen, 
were  free  from  changes  which  could  have  any  bearing  on  the  fatal 
disease. 

From  clinical  observation  it  is  probable  that  an 
acute  primary  and  independent  inflammation  of  the 
inner  ear  occurs  not  infrequently,  and  Voltolini  ^  con- 
siders that  in  childhood  there  is  a  special  predisposi- 
tion to  this  inflammation. 

Secondary  imflammations  of  the  labyrinth  are  found 
with  diseases  of  the  middle  ear,  preferably  purulent 
catarrhs  and  caries,  and  with  diseases  of  the  brain. 
The  most  common  iivQimrulent  inflammation,  the  whole 
labyrinthine  cavity  being  filled  with  pus  and  the 
membranous  structures  destroyed,  while  at  the  same 
time  purulent  inflammation  or  hypero^mia  of  the  tym- 
panum exists.^     The  extension  of  a  purulent  process 

1  M.  f.  0.,  1867,  S.  9-14  ;  1868,  S.  91  ;  1870,  S.  91,  103. 

2  Saissy,  1.  c,  Uebersetzung,  S.  175.     Lucae,  A./.  O.,  v.,  S.  190. 


160  PATHOLOGY  OF   THE  EAR. 

from  the  middle  ear  to  the  labyrinth  takes  place  most 
easily  through  the  labyrinthine  fenestras,  the  mem- 
branes of  which  often  become  perforated,  or  through 
a  fistula  in  the  labj'rinthine  wall  of  the  tympanum. 
The  labyrinth  cavity  has,  however,  been  found  filled 
with  pus,  without  the  existence  of  this  direct  commu- 
nication with  the  tympanum,  by  Viricel,^  Heller,^  and 
Lucae,'^  in  cases  of  cerebro-spinal  meningitis.  Heller 
is  inclined  to  consider  the  inflammation  of  the  laby- 
rinth as  an  extension  of  the  meningitis  (neuritis  de- 
scendens)  along  the  course  of  the  neurilemma  of  the 
acoustic  nerve  on  account  of  the  hj^oergeraia,  and 
ecchymoses  in  that  tissue,  and  the  pus  cells  between 
the  nerve  fibres.  An  extension  of  the  suppuration  in 
the  opposite  direction,  that  is,  towards  the  base  of  the 
skull  along  the  neurilemma  of  the  acusticus,  does  not 
always  result  from  suppuration  of  the  labyrinth,  as 
the  pus  may  become  inspissated,  caseous,  and  remain 
a  long  time  in  the  labyrinth  without  injury.  This  is 
shown  by  many  cases  of  caries,  and  also  by  old  obser- 
vations in  deaf-mutes.*  In  other  cases  the  suppura- 
tion of  the  labyrinth  produces  necrosis  of  that  organ. 
In  a  case  of  caries  of  the  labyrinth-wall  in  a  tubercu- 
lous subject,  which  had  healed,  Wendt°  found  not  only 
detritus  in  the  labyrinth,  but  a  closure  of  the  inner 
meatus  by  connective  tissue,  which  afforded  a  natural 
protection  against  the  extension  of  the  suppuration 
towards  the  base  of  the  brain.  The  nerve  trunks  in 
the  inner  meatus  were  not  destroyed. 

1  Quoted  by  Saissy,  S.  175. 

2  HeWer,  Deittsches  Archiv  fur  KtiniscJie  Medicin,  1867,  Band   iii.,    S. 
482. 

3  A./.  0.,  v.,  S.  188. 

*  Memoirs  of  the  Medi'-nl  Society  of  London  j  vol.  iii.,  S.  1. 
5  Case  34-4  a,  of  his  collection  of  anatomical  preparations. 


THE  INNER  EAR.  — AUDITORY  NERVE.  161 

In  its  lighter  forms  the  inflammation  of  the  laby- 
rinth does  not  go  on  to  suppuration,  but  onh'  produces 
a  small  cell  infiltration,  that  is,  an  infiltration  of  lym- 
phoid corpuscles,  in  the  membranous  labyrinth,  such 
as  Moos  ^  has  described  in  cases  of  caries  of  the  tem- 
poral bone,  and  of  typhus,  variola,  and  scarlet  fever 
associated  with  inflanmiation  of  the  tympanum. 

That  disturbances  of  nutrition  in  the  ultimate  nerve- 
apparatus  of  the  labyrinth,  takes  place  from  the  con- 
tinuous intralabyrinthine  pressure  which  must  neces- 
sarily result  from  many  diseases  of  the  middle  ear,  is 
highly  probable.  The  anatomical  proofs  of  this  are 
however  as  yet  very  few. 

As  the  results  and  remains  of  chronic  inflammation, 
the  following  changes  have  been  seen  and  described  : 
swelling,  thickening  and  atrophy  of  the  membranous 
labyrinth,  fatty  degeneration  of  Corti's  organ,^  con- 
nective-tissue growths  on  the  saccule  and  utricle  of 
the  vestibule,"  growths  of  connective  tissue  from  the 
osseous  to  the  membranous  labyrinth,  filling  of  the 
labyrinthine  cavity  with  a  thick,  yellowish- white  mass 
resembling  detritus  or  with  a  reddish  soft  mass  of 
tissue,  calcifications,  ossifications,*  and  hyperostoses, 
collections  of  pigment  and  cholesterine,  and  changes 
in  the  labyrinth  water  which  is  found  hemorrhagic,^ 
jelly-like,^  opaque,  diminished  and   increased.     Also 

1  Moos,  A./.  A.  und  0..  iii.,  1,  S.  84;  Ibid.,  v.,  S.  245  and  246. 

2  Moos,  vide  A./.  O.,  ix.,  S.  298,  299. 

3  Schwartze,  A./.  0.,  iv.,  S.  245. 

*  Hinton  describes  an  ossification  of  the  saccule.  Moos  (Af.  0.,  ix., 
S.  276,  Fall  8,)  found  with  anchylosis  of  the  ossicula  in  secondary  syph- 
ilis a  deposition  of  lime  concretions  on  the  saccules  of  the  vestibule  and 
on  the  semicircular  canals. 

5  Gruber,  Lehrluch,  S.  617,  note. 

6  Otto,  /.  c. 

11 


162  PATHOLOGY  OF   THE  EAR. 

the  abnormal  increase  or  diminution  of  the  Hme  crys- 
tals, otoliths,  in  the  semicircular  canals  and  the  sacs 
of  the  vestibule,  have  been  referred  to  inflammatory 
processes.^ 

The  use  of  these  lime-crystals  and  the  corpora  amylacea,  which 
are  often  present  in  large  numbers,  is  unexplained,  and  at  least  they 
should  not  be  used  to  account  for  marked  disturbances  of  function. 
Lucae  ^  found  masses  of  fat  and  lime  in  the  ampuUsE  and  vestibular 
sacs  in  a  case  of  acute  purulent  inflammation  of  the  inner  ear  with 
meningitis  epidemica,  where  good  hearing  existed  before  the  fiital 
disease.  In  another  case  Lucae  ^  found  the  membranous  semicircu- 
lar canals  completely  filled  with  lime-crystals  where  there  had  been 
no  inflammation  in  the  ear. 

Voltolini  ^  is  of  the  opinion  that  not  only  the  increase  of  the  oto- 
liths may  be  the  result  of  a  "perverted  nervous  influence"  (namely, 
in  inflammatory  conditions  of  the  inner  ear,  as  caries)  but  that  abnor- 
mal forms  of  these  crystals  may  also  be  produced  by  these  same  in- 
fluences. Usually  these  crystals  are  hexagonal  columns  truncated  at 
the  ends,  but  Krause  ^  has  seen  them  octohedral,  and  Voltolini  pris- 
matic in  form. 

Caries  and  Necrosis. 

Literature,  of  Necrosis  of  the  Labyrinth.  Wilde,  Pract.  Bomerkiingen, 
etc.,  Uebersetzung.  S.  432.  Meniere,  Gaz.  Med.  de  Paris,  1857,  No.  50. 
Fon  rroe//sc/i,Virch.  Arch.  XVII.  S.  47.  Toynbee,  k.  i.  O.  L  S.  112, 
with  a  supplement  at  S.  158.  Gruber,  AUgem.  Wiener  Med.  Ztg.  IX. 
41-45.  Voltolini,  M.i.O.  IV.  S.  85.  Sclucartze,  A.  i.  O.  IX.  S.  238. 
Boeters,  Inaugural-Dissertation,  Halle,  1875.  Dennert,  A.  f.  O.  X.  S. 
231.     Lucae,  Ibid.     S.  236. 

In  very  exceptional  cases  a  caries,  confined  to  the 
labyrinth  without  the  other  portions  of  the  temporal 
bone  showing  any  sign  of  the  disease,  is  found.     An 

^  Papponheiin  and  Voltolini. 

2  A.f.  O.,  v.,  S.  189. 

8  Virchotv's  Archiv,  xxix.,  S.  44. 

*  Ibid.,  xxii.,  S.  126. 

s  Bock's  Anatomie,  2  Aufl.,  ii.,  S.  217. 


THE  INNER   EAR.  — AUDITORY  NERVE.  163 

old  observation  of  this  disease  with  a  figure  is  given 
by  Platner,^  who  found  a  carious  opening  in  the  wall 
of  the  posterior  semicircular  canal  in  an  ear  otherwise 
healthy.  From  carious  destruction  of  the  osseous 
capsule  of  the  labyrinth  at  any  spot  an  incurable  deaf- 
ness results,  owing  to  the  loss  of  the  labyrinth  water 
and  destruction  of  the  ultimate  nervous  apparatus. 

Necrosis  confined  to  the  labyrinth  is  more  common, 
and  is  seen  in  different  stages  from  the  line  of  begin- 
ning demarcation  to  the  complete  separation  and  dis- 
charge of  the  diseased  bone.  Childhood  seems  to  be 
specially  predisposed  to  this. 

Cases  of  necrotic  separation  of  the  cochlea,  either 
alone  or  wath  the  contiguous  parts  of  the  semi-circu- 
lar canals,  have  been  described  most  frequently.  In 
other  less  common  cases,  the  necrosis  affects  the 
whole  labyrinth,  so  that  the  entire  pyramid  including 
the  cochlea,  vestibule,  and  semicircular  canals,  is  sep- 
arated from  its  attachments,  and  its  removal  is  not 
inconsistent  w^ith  life,  provided  that  the  process  of 
demarcation  has  not  already  produced  a  fatal  disease 
of  the  meninges  of  the  brain.  The  first  case  of  this 
kind  was  published  by  Wilde. 

The  usual  course  which  a  sequestrum  of  this  kind 
takes,  is  through  the  labyrinth  wall  of  the  tympanum, 
into  that  cavity,  and  from  there  into  the  meatus. 

Niemetschek,  in  Prague,  has  observed  one  case 
where  the  necrotic  labyrinth  was  throwai  off  through 
the  nose. 

A  beginning  necrosis  of  the  labyrinth  can  be  rec- 
ognized by  the  very  decided  white  color  of  the  bone 
at  the  affected  spot,  and  by  the  line  of  demarcation 

1  Given  in  Schmalz,  Beitrage,  i.,  S.  175. 


164 


PATHOLOGY  OF   THE  EAR. 


surrounding  this  ^pot.  Along  this  line  of  demarca- 
tion the  bone  is  softened,  or  already  at  certain  spots 
separated.  Later  on  in  the  process,  a  new  growth 
of  bone  is  seen  near  this  line.    The  relative  frequency 


Fig.  65. 

Necrosed  Cochlea  discharged  during  life. 

Fig.  a  shows  a  completely  separated  sequestrum  including  the  cochlea,  from  the 
pyramid  of  a  child  two  and  one  half  year's  old,  which  died  from  tubercular  menin- 
gitis. It  is  magnified  three  times,  and  shows  the  sequestrum  when  looked  at  from 
the  upper  surface.  The  upper  half  of  the  illustration  shows  the  first  spiral  of  the 
cochlea,  which  on  the  right  passes  into  the  second  spiral.  On  the  left  of  the  illus- 
tration a  remnant  of  compact  osseous  substance  is  recognized,  which  belonged  to  the 
anterior  wall  of  the  petrous  bone  above  the  canalis  caroticus.  On  the  edge  of  tlie 
posterior  side  of  the  preparation,  a  trace  of  the  meatus  auditorius  internus  remains. 
The  carotid  artery  and  jugular  vein  were  uninjured. 

Fig.  b  shows  the  necrosed  cochlea  of  a  man  thirty -eight  years  old.  The  modio- 
lus with  its  base  turned  towards  the  meatus  auditorius  internus  can  be  seen;  from 
this  a  layer  of  bone  projects  which  corresponds  to  the  inner  wall  of  the  first  and  the 
outer  wall  of  the  second  spiral  of  the  cochlea.  The  lamina  spiralis  ossea  can  be 
traced  in  tlie  preparation  for  nearly  one  and  a  half  spirals.  In  this  case  complete 
recovery  took  place,  leaving  total  deafness  of  this  ear,  and  dizziness  on  violent 
movement.     There  was  no  facial  paralysis. 

Fig.  c  shows  two  views  of  a  necrosed  cochlea  with  the  whole  modiolus,  thrown 
off  during  life  by  a  young  woman;  one  view  is  taken  from  the  apex,  ami  the  other 
from  the  side.  The  formation  of  the  lamina  spiralis  ossea,  is  perfectly  retained. 
Magnified  three  times. 

of  circumscribed  necrosis  of  the  labyrinth  is  ex- 
plained b}^  the  separate  development,  separate  nutri- 
tion, and  very  early  ossification  of  this  part.  It  is, 
in  most  cases,  caused  by  a  caries  of  the  spongy  por- 


THE  INNER  EAR.  — AUDITORY  NERVE.  165 

tion  of  the  pyramid  which  surrounds  the  compact 
bone  of  the  labyrinth,  or  else  it  is  caused  by  the  peri- 
ostitis purulenta  within  the  labyrinth  which,  as  we 
have  seen,  results  from  suppuration  of  the  tympanum. 
In  the  very  rare  cases  which  run  an  acute  course, 
and  are  not  preceded  by  a  long  otorrhoea,  the  cause  of 
the  necrosis  is  perhaps  an  embolus  of  the  arteria  au- 
dit! va  interna. 

New  Growths  in  the  Labyrinth.  New  growths  of  con- 
nective tissue  have  been  already  described  under 
inflammation.  Exostoses  have  been  several  times 
found  in  the  vestibule,  three  times  by  Toynbee,  and 
an  old  case  of  this  kind  is  described  by  Platner.^  In 
the  cupola  of  the  cochlea,  Voltolini  ^  found  a  "  fibro- 
muscular  "  tumor.  A  doubtful  granulation-like  sar- 
coma in  the  vestibule  was  described  by  me.^ 

In  the  vestibule,  and  almost  filling  that  cavity,  lay  a  mass  of  tis- 
sue of  a  dark-red  color  ;  this  could  be  picked  to  pieces  with  the 
greatest  difficulty,  and  showed  under  the  microscope  very  numerous 
blood-vessels  laying  in  a  tissue  composed,  for  the  most  part,  of  small, 
generally  round  or  oval  cells,  and  a  small  amount  of  fibrous  inter- 
mediate substance.  There  was  no  pus  in  the  vestibule ;  its  osseous 
walls  were  healthy,  except  a  spot  of  caries  the  size  of  a  pea,  on  the 
lower  wall  in  the  centre  of  the  otherwise  healthy  pars  petrosa. 

Whether  cholesteatoma  occurs  primarily  in  the  laby- 
rinth, is  doubtful.  Boettcher  suspects  it  may  arise 
from  the  epithelium  of  the  aquasductus  vestibuli.  A 
cholesteatoma  arising  from  the  tympanum  can  extend 
to  the  labyrinth  secondarily. 

In  the  membranous  semicircular  canals,  small  elevations,  papilla, 
of  the  pavement  epithelium  on   the  basal  membrane,  occur,  which 

1  De  Auribus  Defectivis,  Diss.  Inaug.,  Marbui'g,  1838,  with  an  illustration. 

2  Virchow's  ArcJiiv,  xxii.,  1,  2. 

3  yl.  /.   0,  ii.,  S.  285. 


166  PATHOLOGY  OF   THE  EAR. 

are  considered  by  Lucae  ^  to  be  pathological  formations,  but  by  Ru- 
dinger,^  are  described  as  normal  villi  of  these  canals.  Recently 
they  have  been  considered  normal  by  Utz^  also,  on  account  of  their 
constant  existence  and  their  regular  arrangement  and  development. 
In  new-born  children  these  prominences  do  not  exist. 

Tuberculosis  of  the  inner  ear  (cochlea  and  semi- 
circular canals),  an  extension  of  the  same  disease 
from  the  tympanum,  occurs  frequently  in  pigs,  ac- 
cording to  Schlitz.*  The  growth  may  extend  from 
the  labyrinth  into  the  connective  tissue  of  the  nervus 
acusticus,  and  thus  reach  the  meatus  internus  and  the 
cranial  cavity. 

Injuries.  The  labyrinth  is  so  protected  by  its  sit- 
uation and  its  osseous  capsule,  that  direct  injuries 
reach  it  only  in  very  rare  cases ;  indirect  injuries,  on 
the  contrary,  are  common  in  fractures  of  the  skull, 
which  extend  through  the  petrous  bone,  producing 
effusion  of  blood  and  laceration  of  the  membranous 
labyrinth.  Direct  injuries  from  the  penetration  of 
needles  or  other  sharp  substances  into  the  inner  ear, 
with  penetration  of  the  labyrinth  wall,  fracture  of 
the  stapes,  and  laceration  of  the  soft  parts  of  the  ves- 
tibule, have  been  reported  in  very  small  numbers.  A 
case  of  this  kind  will  be  found  in  the  "  Gazette  des 
Hopitaux,"  1857,  No.  130  with  the  autopsy,  which 
showed  an  extravasation  of  blood  on  the  petrous 
bone,  and  purulent  meningitis.  In  a  dog  a  spike  of 
grass  was  once  found  which,  entering  the  meatus 
and  tympanum,  penetrated  to  the  cochlea.    Lesions  of 

1  Virchotv's  Arcliiv,  xxvii.,  S.   169. 

2  A.  f.  0.,  ii.,  1867. 

*  Beitrage  zur   Histologie   der  Hdutigen  Bogengdnge,  etc.,   Miinchen, 
1875. 
«    Virchotv's  Archiv,  Bd.  66,  S.  93. 


THE  INNER   EAR.  — AUDITORY  NERVE.  167 

the  inner  ear,  with  fatal  result,  are  more  commonly 
caused  by  the  pouring  into  the  meatus  of  concentrated 
mineral  acids,  or  of  molten  metal,  with  a  criminal 
intent.^ 

With  fissures  in  the  pars  petrosa  which  pass  through 
the  inner  ear,  there  is  a  discharge  of  serous  fluid  from 
the  meatus  if  the  membrana  tympani  has  been  in- 
jured, or  if  the  fissure  has  extended  to  the  walls  of 
the  meatus.  It  has  already  been  remarked,  on  page 
20,  that  this  injury  is  not  necessarily  fiital.  In  all 
cases,  however,  absolute  deafness  results,  and  if  the 
fissure  extends  through  both  petrous  bones,  as  some- 
times occurs,  the  deafness  is  bilateral. 

Diseasesof  the  Auditory  Nerve.  Congenital  absence  of 
the  auditory  nerve  beginning  at  its  point  of  entrance 
into  the  petrous  bone  has  only  been  noticed  with 
simultaneous  absence  of  the  labyrinth.  Acquired 
loss  of  the  branches  of  the  auditory  nerve  may  result 
from  inflammation  and  from  new  growths. 

Hypercumia  of  the  neurdemma  is  seen  as  a  post- 
mortem change,  but  it  also  occurs  with  neuritis.^ 

Old  and  recent  apoplexies  in  and  around  the  trunk 
of  the  nerve  have  been  observed  after  injuries,  and 
also  in  connection  with  fatty  degeneration  of  Corti's 
organ  (Moos). 

Atro'pliy  as  a  secondary  process  in  the  nerve  trunk 
or  its  branches  is  only  known  to  take  place  from  dis- 
ease of  the  parts  of  the  brain  from  which  the  nerve 
originates,  cerebellum,  fourth  ventricle,  medulla  ob- 

^  Osiander,  XJeber  den  Selbxtmord,  S.  395,  narrates  the  case  of  an 
Englishwoman  who  killed  six  husbands,  one  after  another,  by  i)ouring 
molten  lead  into  the  ears  when,  they  were  asleep. 

2  Compare  p.  168. 


168  PATHOLOGY  OF   THE  EAR. 

loiigata  ;  from  hydrocephalus  internus,  from  apoplexy 
and  softening  of  the  brain,  or  from  atrophy  of  those 
parts  to  which  it  is  distributed,  i.  e.  the  ultimate  nerv- 
ous apparatus.^  Atrophy  from  this  latter  cause  ap- 
pears to  be  developed  often  from  the  loss  of  function 
of  the  peripheral  conducting  apparatus.  It  is  also 
caused  by  the  pressure  of  tumors  at  the  base  of  the 
skull,  by  tumors  of  the  brain,  by  extravasations  of 
blood  in  the  porus  acusticus  internus,  by  periostitis 
of  the  porus  acusticus,^  and  by  neuritis. 

According  to  Erb  ^  atrophy  of  the  acusticus  now 
and  then  occurs  with  tabes.  I  myself  have  never  seen 
such  a  case.  Whether  the  disturbances  in  the  nervus 
acusticus,*^  which  were  observed  by  Duchenne  and 
Bourdon,  were  dependent  on  the  extension  of  the 
pathological  process  to  the  base  of  the  skull,  was  not 
decided.  Lucae,  who  alone  has  reported  accurate  dis- 
sections of  the  ear  in  cases  of  gray  degeneration  of 
the  spinal  cord  with  deafness,  says  that  he  found  no 
disease  in  the  acusticus.^ 

From  long-continued  loss  of  function  in  the  periph- 
eral apparatus,  especially  from  anchylosis  of  the  stapes 

1  According  to  O.  Weber  (Pitha  ami  Billroth,  i.,  S.  344),  when  the 
inner  ear  has  been  destroyed  the  acusticus  does  not  show  atrophy,  but, 
as  a  rule,  fatty  degeneration,  which  may  extend  even  into  the  parts  of 
the  nerve  within  the  brain. 

2  According  to  Beck  (Krankheiien  des  Gehororgona,  S.  120,  124),  this 
was  observed  by  Soemmering.  Toynbee,  Catalogue,  791,  792.  Zeissl, 
Constitutionelle  Syphilis,  Erlangen,  1864,  S.  297.  A  case  of  paralysis 
due  to  compression,  and  of  atrophy,  produced  by  an  osseous  constriction 
of  the  meatus  auditorius  internus  from  periostitis  ossificans  syphilitica. 
Hinton,  Gwfs  Hospital  Reports,  1867  :  two  cases. 

3  Kranlheiten  des  Rilclemnarks  in  Ziemsscns  Handhuch,  xi.,  2,  1  Ab- 
theilung,  S.  142. 

^  Friedreich,  Degeneratice  Atropine  der  Spinalen  Hinterstrdnge, 
6  Compare  A./.  0.,  ii.,  S.  305. 


THE   INNER   EAR.  — AUDITORY  NERVE.  169 

associated  with  immobility  of  the  membrane  of  the 
fenestra  rotunda,  is  often  developed  a  centripetal 
progressive  atrophy ;  this,  however,  is  by  no  means 
a  constant  result.  Haighton  found  atrophy  of  the 
nerve  associated  with  inspissated  pus  in  the  laby- 
rinthine cavities. 

Tumors  may  force  themselves  into  the  porus  acusti- 
cus,  produce  atrophy  of  the  nerve  trunk,  and,  in  addi- 
tion, as  Boettcher^  found,  may  produce  atrophy  in  the 
nerve-fibres  and  ganglion  cells  of  the  ultimate  nerv- 
ous apparatus  of  the  labyrinth,  and  also  complete  dis- 
appearance of  the  inner  and  outer  hair-cells,  while  all 
the  other  parts  of  the  ultimate  acoustic  apparatus  of 
the  cochlea  remain  intact.  Tumors  may  also  produce 
a  very  decided  enlargement  of  the  osseous  canal  and 
extensive  destruction  in  the  petrous  bone.'^ 

Neuritis  of  the  acusticus  has  been  proved  to  exist 
only  with  fissure  of  the  petrous  bone,  with  caries  and 
with  cerebro-spinal  meningitis.  The  nerve  trunk  is 
reddened  and  swollen,  surrounded  with  and  infiltrated 
by  pus,  and  in  the  more  advanced  stages  of  the  dis- 
ease is  softened  and  destroyed. 

The  presence  of  a  large  amount  of  corpora  amy- 
lacea  between  the  nerve-fibres  of  the  trunk  of  the 
acusticus,  which  has  been  falsely  designated'^  "amy- 
loid degeneration  of  the  acusticus,"  is  generally  to 
be  regarded  as  an  accompaniment  of  atrophy  of  the 
nerves.*     The  corpora  amylacea  are  seen  associated 

1  Vide  A.f.  0.,  vi.,  S.  279. 

'■^  An  instance  of  this  is  seen  in  Figure  10. 

2  Voltolini,  Virchotv's  ArcJiiv,  xviii.,  xx.,  xxii. 

^  G.  Meissner,  Zeitschrift  fiir  Rat.  Med.  N.  F.,  iii.,  3,  1853.  Foerster, 
Atlas  (ler  Path.  Hlstolor/ie,  1856,  Taf.  xviii.  The  liistological  details  are 
most  accurately  given  by  Schweigger-Seidel.  (Virch.  Arch.,  Bd.  xxii., 
S.  114.) 


170  PATHOLOGY  OF   THE  EAR. 

with  nucleated  cells  lying  in  the  hypertrophied  in- 
termediate-substance of  the  nerves,  which  is  formed 
of  connective  tissue  (nucleated  connective  tissue,  pro- 
cesses of  spindle-cells)  ;  the  nerve  fibres  themselves 
appear  to  have  undergone  fatty  degeneration  and  to 
have  disappeared.  It  should  be  added  that  these  cor- 
puscles are  found  in  variable  quantities  in  the  trunk 
of  every  normal  nerve. 

The  supposition  of  Hyrtl  ^  that  atrophy  of  the 
acusticus  is  found  in  all  deaf-mutes  is  incorrect. 

Fibrous  degeneration  may  lead  to  hardening  of  the 
nerve  so  that  it  becomes  firmer  than  the  facialis. 

New  growths  in  the  trunk  of  the  acusticus,  or  its 
branches,  ramus  cochleae  et  vestibuli,  are  reported  as 
follows  :  — 

Fibromata  were  found  by  Gruber,^  especially  wdth 
caries  of  the  temporal  bone.  The  ganglion-like  swel- 
lings on  the  ramus  cochlea,  which  were  found  by 
Fleischmann  ^  probably  also  belong  to  this  category. 
In  a  case  by  Leveque-Lasource,*  a  fibroma  fourteen 
lines  in  diameter  occupied  the  meatus  internus  of 
an  old  woman  who  had  become  gradually  deaf  and 
blind. 

Sarcomata  are  quite  common  on  the  acusticus,  ac- 
cording to  Foerster.^  A  case  is  given  by  Voltolini,^ 
and  by  Moos.' 

Neuromata.      Cases   are   given  by  Virchow,^  and 

1  Topogr.  Anatomic,  1857,  i.,  S.  228. 
^  LeJirbuch,  S.  545. 
3  Hufeland's  Journal,  1840,  Heft  1. 
*  Lincke,  Handhuch  der  Ohrenh.,  i.,  S.  651. 
5   Witrzb.  Med.  Zeitschrift,  iii.,  S.  199 
^  Virchow's  ArcJiiv,  xxii.,  S.  125. 

■^  Compare  A.f.  O.,  ix.,  S.  298,  with  fatty  metainorpliosis  and  partial 
loss  of  Corti's  organ. 

s  Geschwiilste,  ii.,  S.  151,  iii.,  S.  295. 


THE   INNER   EAR.  —  AUDITORY  NERVE.         171 

by  Klebs.^  A  number  of  the  so-called  neuromata  of 
the  acusticus  arise  in  reality  from  the  neuroglia,  and 
are  therefore  to  be  referred  to  the  gliomata.^ 

Gummata  of  the  brain  or  base  of  the  skull  may 
affect  the  trunk  of  the  acusticus.^ 

Concretions  of  carbonate  of  lime  were  found  by 
Boettcher  ^  on  the  periosteum  of  the  porus  acusticus 
internus  and  also  in  the  neurilemma,  particularly  in 
persons  of  middle  age. 

Tumors  of  the  petrous  bone,  which  arise  from  the 
dura  mater,  may  produce  compression,  consequent 
atrophy,  and  complete  destruction  of  the  trunk  of 
the  nerve.  In  a  child  aged  two  years,  I  found  a  mass 
of  tubercle,  the  size  of  a  pigeon's  Qgg,  arising  from 
the  dura  mater,  and  lying  at  the  entrance  of  the 
meatus  auditorius  internus,  which  had  produced  pa- 
ralysis of  the  facialis  and  acusticus  by  compression : 
there  was  no  caries.^ 

Virchow  ^  figures  a  psammoma  of  the  dura  mater 
as  large  as  a  mulberry,  which  was  attached  by  a 
broad  base  at  the  entrance  of  the  meatus  internus, 
extended  a  short  distance  into  the  osseous  canal,  and 
had  produced  paralysis  of  the  facialis  and  acusticus 
by  compression. 

Rayer'  describes  a  case  of  unilateral  deafness  ap- 
parently due  to  a  syphilitic  tumor  as  large  as  a  pig- 
eon's egg  in  the  fossa  of  the  petrous  bone. 

^  Prager  Vierteljahresschrift,  1877,  S.  65.  The  tumor  filled  the  inner 
meatus.  The  facialis  had  completely  disappeared  in  the  tumor;  the  acus- 
ticus remained  distinct. 

2  Virchow's  Geschivulste,  ii.,  S.  151.  3  Ibid.,  S.  463. 

*  Virchow'' s  Archiv,  Bd.  xvii.,  S.  104. 
6  A.f.  0.,  v.,  S.  296. 

*  Geschwiilste,  ii.,  S.  116. 

'  Gross  and  Lanccreaux,  Ajfect.  Nervi  Syphil.,  Paris,  1861,  S.  381. 


172  PATHOLOGY  OF   THE  EAR. 

Other  iniracratiial  processes,  both  basilar  and  cere- 
bral, which  may  produce  disease  of  the  acusticus,  are : 
basilar  meningitis,,  by  pressure  of  its  exudation  on  the 
oedematous,  softened  nerve  trunk,  or  by  cicatricial 
contraction  of  the  arachnoid  membrane;  aneurism  of 
the  arteria  basilaris ;  ^  hydrocephalus  internus  ;  tu- 
mors of  the  brain.^ 

According  to  Calmeil,  disturbances  of  hearing  occur 
in  one  ninth  of  all  cases  of  tumors  of  the  brain.  Ac- 
cording to  the  tables  of  Ladame,^  in  seventy-seven 
cases  of  tumor  of  the  cerebellum,  disturbances  of  hear- 
ing occurred  seven  times  ;  in  twenty-six  cases  of  tu- 
mors of  the  pons  they  occurred  seven  times;  in  twen- 
ty-seven cases  of  tumors  of  the  middle  lobes,  three 
times;  on  the  other  hand,  no  disturbances  of  hearing 
occurred  in  twenty-seven  cases  of  tumors  of  the  ante- 
rior lobes,  in  fourteen  of  the  posterior  lobes,  and  in 
four  of  the  fourth  ventricle.  In  a  number  of  tumors 
of  the  brain  unilateral  disturbances  of  hearing  were 
the  first  symptoms  of  the  disease,  as  has  been  shown 
by  Cruveilhier.  Tumors  of  the  cerebellum  not  infre- 
quently produce  bilateral  total  deafness,  beginning 
first  on  the  side  corresponding  to  the  tumor ;  and  this 
bilateral  deafness  may  occur  even  in  cases  where  a  di- 
rect pressure  of  the  tumor  on  the  nerve  trunk  of  the 
second  ear  or  on  its  nucleus  in  the  medulla  oblon- 
gata is  utterly  impossible,  and  where  other  symptoms 
of  paralysis  of  other  nerves  of  the  brain  or  spinal 
cord    on    the    second    side    are    also   wanting.      Per- 

^  Toynboe,  Catologue,  No.  772.  Griesingor,  Archie  fur  Heilkunde, 
1862,  6  Heft.     Lebert,  Berliner  Kiln.  Wochenschrift,  1866. 

^  An  old  case  by  Lincke,  Han.dhnch  der  Ohrenheilkunde,  i.,  S.  G50-653. 

^  Symjitomatologie  und  Diagnostik  der  Gehingeschwiilste,  Wurzburg, 
1865. 


THE   INNER  EAR.  — AUDITORY  NERVE.  173 

haps  in  such  cases  there  exists  a  neuritis  of  the  ulti- 
mate nervous  apparatus  in  the  labyrinth,  or  possibly 
only  an  interference  of  function  due  to  fluxionary 
oedema. 

Bruckner  ^  describes  a  case  of  tumor  within  the 
skull  where  the  auditory  nerve  trunk  was  completely 
torn  across  by  the  dragging  of  the  mass.  As  the  re- 
sults of  fractures  of  the  skull,  a  similar  tearing  of  the 
nervous  acusticus  with  an  intact  facialis  has  been 
found. 

As  a  cause  of  deafness,  in  addition  to  the  direct 
compression  of  the  nerve  trunk  by  a  tumor  and  com- 
pression of  the  parts  of  the  brain  from  which  the 
nerve  arises,  should  be  mentioned  softening  of  the 
brain-substance  in  the  neighborhood  of  the  tumor  at 
its  point  of  insertion  in  the  brain.  It  should  also  be 
remembered  that  simultaneously  with  the  brain  dis- 
ease, peripheral  disease  in  the  conducting  apparatus 
may  occur  which  alone  may  be  sufficient  to  account 
for  the  disturbances  of  function.  Especially,  often  I 
have  found  anchylosis  of  the  stapes  associated  with 
atrophy  of  the  brain  (dementia  paralytica),  and  also 
with  tumors  of  the  brain.^ 

Pathological  changes  in  the  fourth  ventricle  appear 
to  have  much  less  influence  in  producing  disturbances 
of  hearing  than  was  formerly  supposed.  Thickening 
of  the  ependyma,  which  has  been  spoken  of  as  some- 
thing of  importance'^  in  the  dissection  of  deaf-mutes, 
is  very   commonly   found   in  various  diseases  of  the 

^  Berliner  Kim.  Wochenschrift,  18(57,  No.  29. 

2  Vide  A.f.  0.,  ii.,  S.  289,  Fall  8. 

3  H.Meyer,  Zur  Analomie  fJer  Taiibstummheit,  VircTi.  Arch.,  xiv.,  5, 
6,  p.  551,  1858.  Voltolini,  Ibid.,  xxvi.,  S.  171,  1863.  Falk,  Zur  Sta- 
tistik  der  Taubstummen,  Arcluf.  Psychiatrie,  iii.,  S.  418. 


174  PATHOLOGY  OF   THE  EAR. 

brain,  especially  in  insane  persons,  where  not  the 
slightest  disturbance  of  hearing  existed  :  when  found 
in  deaf-mutism  it  can  be  considered  only  as  an  inci- 
dental appearance.  Tumors  in  the  fourth  ventricle 
have  been  found  several  times  without  any  disturb- 
ance of  the  hearing  having  existed.^  Even  complete 
absence  of  the  striae  acusticse  is  not,  according  to 
Engel,  accompanied  by  deafness.^ 

Disturbances  of  the  ear  are  but  rarely  the  result  of 
hemorrhages  in  the  brain,  or  of  encephalic  collections  ; 
according  to  Moos  they  are  most  common  with  uni- 
lateral apoplexy  in  the  pons.  Whether  they  may 
also  be  produced  temporarily  by  simple  liypera3mia 
of  the  brain  and  its  membranes  (arterial  fluxion  with 
oedema  or  venous  congestion)  is,  to  judge  from  clini- 
cal observations,  certainly  probable,  but  has,  however, 
never  been  recognized  anatomically.  As  Bottcher  ^ 
has  already  said,  very  continuous  and  laborious  work 
is  still  needed  in  order  to  throw  more  light  anatomi- 
cally on  cerebral  deafness.  After  previous  hardening 
of  the  brain  the  whole  region  wdiere  the  central  gan- 
glia lie,  from  which  the  fibres  of  the  acusticus  arise, 
must  be  successively  dissected. 

1  Ladame,  S//mpiomatoloffie  unci  DkifinoMik  der  Himgescliwiihtc,  Wiirz- 
burg,  1865.  In  four  tumors  of  the  fourth  ventricle  no  disturbance  of 
hearing.  Foerster,  Wiirzb.  Med.  Zeilschr.,  Bd.  iii.,  Heft  3.  Cjsticercus 
in  the  fourth  ventricle.     Hydrocephalus  intornus. 

2  Wicnei-  Wochensclirift,  1862,  No.  60. 

3  Bocttcher,  Archiv  f.  A.  u.  0.,  ii.,  2. 


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